Download Foot and Ankle Amputations: Lisfranc/Chopart

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Chapter
42
Foot and Ankle Amputations:
Lisfranc /Chopart
Loretta B. Chou, H. Thomas Temple, Yvette Ho, and
Martin M. Malawer
BACKGROUND
3,7,10,12,15,16
Tumors of the foot and ankle are rare.
In the
senior author’s experience, 153 cases were treated.
■ FIGURE 1A shows all anatomic sites, FIGURE 1B shows
the distribution of malignant and benign cases, and FIGURE
1C shows the distribution of all types of surgical procedures.
■ Patients with tumors of the metatarsals complain of pain
with an associated mass. The mass may be small and chronic.
It may be first noticed after a minor injury. The patient may
have difficulty with weight-bearing activities, including walking and standing. Shoe wear, particularly fashionable shoes,
may be limited.
■ Physical examination often shows a tender mass localized to
the metatarsal with some swelling. If a sensory nerve overlies
the mass, there may be paresthesias. If the mass is large, there
may be loss of motion, or discomfort with active range of motion of the foot and ankle.
■ For extensive disease of the forefoot involving the first and
second interspace in adjacent metatarsals or multiple
metatarsals, a Lisfranc amputation or a transmetatarsal amputation is indicated (FIG 2A–C). These amputation levels are highly
functional with minor shoe-wear modifications and forefoot
fillers. If the metatarsal bases can be preserved using a transmetatarsal amputation, the functional outcome is improved.
■ Careful preoperative evaluation is necessary, and MRI is especially important to assess the extent of marrow change in the
metatarsals to ascertain the appropriate level of amputation.
■ For tumors extending to the tarsometatarsal joint with soft
tissue extension, a Chopart amputation is a consideration. The
Chopart amputation is a transtarsal amputation that preserves
the talus and calcaneus. The disadvantage of the Chopart amputation is the loss of the dorsiflexors of the foot, which allows unopposed action of the Achilles tendon, resulting in an
equinus contracture.
■ To circumvent this problem, the tibialis anterior is used. It
is detached from the tarsal navicular with a cuff of soft tissue,
preferably periosteum. A drill hole is made through the neck
and head of the talus in an oblique fashion from dorsolateral
to plantar-medial. The tendon is then routed through this bone
tunnel and sewn to itself or soft tissue as it exits through the
tunnel. This repair may be augmented with bone anchors
placed near the dorsal opening of the tunnel. The residual foot
is maintained in maximal dorsiflexion (FIG 2D,E).
■ The advantage of a Chopart amputation over a Syme amputation is the maintenance of hindfoot height. This is an endbearing residual limb and the patient can negotiate short
distances without modified shoe wear or prosthetic fitting.
■
ANATOMY
The Lisfranc joint is the tarsometatarsal joint. An amputation
at this level will preserve the dorsiflexors and plantarflexors.
■
The Chopart joint is also known as the transverse tarsal
joint. It includes the talonavicular and calcaneocuboid
joints. An amputation at this level preserves the plantarflexors but sacrifices the dorsiflexors, often resulting in an equinus contracture.
■
INDICATIONS
Lisfranc
Extensive tumor involving the first and second interspace in
adjacent metatarsals or multiple metatarsals
■
Chopart
Tumors extending to the tarsometatarsal joint with soft tissue extension. FIGURE 3 shows the pathology specimen after
wide resection of a chondrosarcoma involving multiple small
bones of the foot.
■
IMAGING AND OTHER STAGING
STUDIES
Preoperative studies include plain radiographs of the foot,
including anteroposterior, lateral, and oblique views. If there
is involvement of the ankle joint, then anteroposterior and
mortise views are obtained as well. MRI is important to evaluate the amount of involvement of the metatarsals to determine the level of amputation. It also shows the extent of soft
tissue tumors and may be helpful in distinguishing benign
from malignant tumors.17
■ MRI is helpful for assessing soft tissue involvement.
FIGURE 4A,B shows a chondrosarcoma of the calcaneus, and
the MRI shows extension into the soft tissue. It was treated
with cryosurgery but recurred, and a below-the-knee amputation was performed.
■ FIGURE 4C,D shows an example of a unilateral calcaneal
brace (UCB). The radiograph shows the typical expansile appearance of the UCB. The CT scan shows greater bony detail.
The lesion was treated with curettage, graft, and polymethylmethacrylate (PMMA).
■
SURGICAL MANAGEMENT
The goal of the surgical procedure is remove the tumor with
adequate margins. FIGURE 5 illustrates a case of osteosarcoma of the calcaneus. Osteosarcoma is usually treated with
wide resection, but in this case the tumor was confined to the
calcaneus. The patient had a good response to adjuvant
chemotherapy, with 100% tumor necrosis, and was treated
with the only calcaneal prosthesis reported in the world.
■ A long plantar flap is important for a sturdy end-bearing
stump.
■ The quality of the tissue is more important than the quantity.1
■ The bony edges should be smooth and beveled if possible. An
example is the Lisfranc amputation, in which the cuneiforms
■
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FIG 1 • A. All anatomic sites of tumors of the foot and
ankle (n ⫽ 153). B. Distribution of malignant and benign tumors of the foot and ankle (n ⫽ 153). C.
Distribution of surgical procedures for tumors of the
foot and ankle (n ⫽ 153).
A
B
C
A
B
C
FIG 2 • Chopart amputation has a poor reputation because many patients develop an equinus contracture. With
transfer of the tibialis anterior to the neck of the talus, this problem can be avoided. This case is an example of synovial sarcoma involving the forefoot. A. This patient’s radiographs showed radiodensity surrounding the second
metatarsal, a typical radiographic appearance of a synovial sarcoma. B,C. MRI shows extensive soft tissue mass. The
patient was treated with a Chopart amputation. (continued)
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D
3
FIG 2 • (continued) D. Postoperative photograph shows
good dorsiflexion function. E. Chopart amputation can
be successful with the transfer of the tibialis anterior into
the talar neck. This patient also had a Marcaine catheter
placed for postoperative pain control (A).
E
FIG 3 • Chondrosarcoma can spread to involve multiple sites.
This photograph shows the pathology specimen after a below
knee amputation of a chondrosarcoma involving multiple small
bones of the foot.
A
B
C
D
FIG 4 • Chondrosarcoma of the calcaneus. A,B. MRI shows extension into the soft tissue. It was treated with cryosurgery but recurred, and a below-knee amputation was
performed. C,D. UCB of the calcaneus. The radiograph shows the typical expansile appearance of the UCB. The CT scan shows greater bony detail. The lesion was treated
with curettage, graft, and polymethylmethacrylate.
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A
D
B
C
should be contoured to a rounded end. In a Chopart amputation, the talus and calcaneus should be cut and contoured to fit
a prosthesis.
■ Myodesis is helpful to pad the end of the stump.
■ Reconstruction of the anterior tibialis tendon insertion into
the neck of the talus in the Chopart amputation will help prevent an equinus contracture.
Preoperative Planning
Preoperative planning is crucial for a good outcome. The
preoperative radiographs and CT and MRI studies are important to determine the amount of tumor involvement. The
results of the biopsy will determine the level of amputation.
TECHNIQUES
■
FIG 5 • Osteosarcoma is an aggressive malignant tumor that has been
reported to occur in the calcaneus.
Osteosarcoma is usually treated with
wide resection, but in this case the
tumor was confined to the calcaneus.
The patient had a good response to
adjuvant chemotherapy, with 100%
tumor necrosis, and was treated with
the only calcaneal prosthesis reported
in the world. The lateral radiograph
(A) shows the expansile tumor. The
bone scan (B) shows isolated involvement. Postoperatively, at 10 years,
the patient is tumor-free and enjoys
working and normal activities (C,D).
Positioning
The patient is placed supine on the operating table. A thigh
tourniquet is placed over adequate padding, such as Webril. A
bump may be placed proximal to the sciatic notch on the ipsilateral hip to limit external rotation of the extremity during
the procedure.
■
Approach
Lisfranc and transmetatarsal amputations are performed
through a midfoot incision, with a long plantar flap. This is
the same approach with the Chopart amputation. The plantar
skin is thicker and has specialized columns of plantar fat to
provide for a weight-bearing stump.
■
TRANSMETATARSAL AMPUTATION
■
■
■
A transverse incision is made either at the middle or
proximal third of the metatarsals, extending through
skin into the subcutaneous tissue (TECH FIG 1A,B).
The cutaneous branches of the terminal portions of the
peroneal nerve are identified. Traction is applied, pulling
the nerve distally. The nerve is transected sharply to
allow it to retract proximally.
The terminal branch of the dorsalis pedis is preserved if
possible to maintain continuity of the anastomosis with
■
■
the posterior tibial terminal arterial branch, thus maintaining the dorsalis pedis contribution of arterial flow
through the arch.
The extensor tendons are placed on a stretch, and this is
best accomplished by flexing the forefoot and sharply dividing the tendons at the level of the skin incision, allowing the tendons to retract proximally.
A beveled cut is made in the metatarsal heads by angling
an oscillating saw 30 degrees from the perpendicular
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to suture the extensor tendons to the flexor tendons.
If there is a significant plantar extension of the tumor, a
long plantar flap cannot be used. In this case, a fishmouth configuration is preferable. To achieve this, equal
dorsal and plantar flaps are constructed and the same
operation is carried out as indicated above.
The tourniquet is deflated and meticulous hemostasis is
obtained. Excessive use of cautery to obtain hemostasis is
discouraged to limit dysvascularity of the plantar flap.
The plantar flap is brought up and myodesed to the
residual metatarsals or tarsal bones. Alternatively, the
plantar fascia can be sewn into the periosteum overlying
the residual metatarsal heads or capsular structures in
and around the tarsal bones.
The skin is closed with 4-0 nylon sutures. A Penrose drain
is placed deep to the flap and brought out either medially or laterally through the incision.
■
■
■
■
A
B
TECH FIG 1 • A,B. Surgical technique for transmetatarsal amputation. Dorsal and plantar skin incisions. Bone
cuts are made with a sagittal saw.
LISFRANC AMPUTATION
■
■
A transverse incision is made either at the middle or
proximal third of the metatarsals, extending through
skin into the subcutaneous tissue (TECH FIG 1C,D).
The cutaneous branches of the terminal portions of the
peroneal nerve are identified. Traction is applied, pulling
the nerve distally. The nerve is transected sharply to
allow it to retract proximally.
■
■
The terminal branch of the dorsalis pedis artery is ligated
and divided as it enters the first dorsal interspace and
courses in the plantar fascia.
The extensor tendons are placed on a stretch; this is best
accomplished by flexing the forefoot and sharply dividing
the tendons at the level of the skin incision, allowing the
tendons to retract proximally.
TECHNIQUES
■
with the foot placed in neutral position on the operating
table. A plantar flap is then fashioned by extending the
incision through the skin approximately 45 degrees from
the transverse dorsal incision obliquely across the medial
and lateral foot to the level of approximately the
metatarsal heads and then transversely across the skin
just proximal to the metatarsal heads.
The sensory nerve to the first ray is identified, traction is
placed, and the nerve is transected sharply. The terminal
branches in the medial plantar nerve are identified as
well, placed on stretch, and sharply divided. The terminal
branches of the medial plantar artery are identified, ligated, and divided.
The superficial and deep flexor tendons are placed on
stretch by dorsiflexing the forefoot through the
metatarsal osteotomies and sharply dividing them, allowing them to retract proximally. No attempt is made
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■
■
■
The Lisfranc joint is disarticulated sharply. A plantar flap
is fashioned by extending the incision through the skin
approximately 45 degrees from the transverse dorsal
incision obliquely across the medial and lateral foot to
the level of the distal metatarsals.
The sensory nerve to the first ray is identified, traction is
placed, and the nerve is transected sharply. The terminal
branches in the medial plantar nerve are identified,
placed on stretch, and sharply divided.
The terminal branches of the medial plantar artery are
identified, ligated, and divided. The superficial and
deep flexor tendons are placed on stretch by dorsiflexing the forefoot through the Lisfranc joint and sharply
dividing them, allowing them to retract proximally. No
attempt is made to suture the extensor tendons to the
flexor tendons.
■
■
■
C
If there is a significant plantar extension of the tumor, a
long plantar flap cannot be used. In this case, a fishmouth configuration is preferable. To achieve this, equal
dorsal and plantar flaps are constructed and the same
operation is carried out as indicated above.
The tourniquet is deflated and meticulous hemostasis is
obtained. Excessive use of cautery to obtain hemostasis is
discouraged to limit dysvascularity of the plantar flap.
The plantar flap is brought up and myodesed to the
tarsal bones. Alternatively, the plantar fascia can be
sewn into the periosteum overlying the capsular structures in and around the tarsal bones. The skin is closed
with 4-0 nylon sutures, and a small drain is placed deep
to the flap and brought out either medially or laterally
through the incision.
D
TECH FIG 1 • C,D. Surgical technique for Lisfranc amputation. Skin incisions on the dorsal
and plantar aspects of the foot. The plantar skin flap is longer. Dissection and removal of
the metatarsals. Wound closure with sutures.
CHOPART AMPUTATION
■
■
The Chopart amputation is performed through a transverse incision that is dorsally based at or just distal to the
talonavicular joint (TECH FIG 1E,F).
The dorsalis pedis artery and accompanying nerve are
identified. The dorsalis pedis artery is ligated and di-
E
■
vided, and the sensory nerve is placed on stretch and
transected sharply, allowing it to retract proximally.
The capsule of the talonavicular joint is circumferentially
divided, along with release of the posterior tibial tendon. This tendon is tagged for later use as it is brought
F
TECH FIG 1 • E,F. Surgical technique for Chopart amputation. Skin incisions with dorsal and plantar flaps.
Dissection and removal of bones. Attachment of tibialis anterior tendon into the neck of the talus through
drill holes. Wound closure with sutures.
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■
■
■
■
■
■
■
■
The posterior tibial tendon and the flexor hallucis longus
and brevis tendons are divided; the tendons are allowed
to retract proximally unless the posterior tibial tendon is
used to augment the dorsiflexion repair.
The plantar branch of the posterior tibial artery is located, ligated, and divided. The flaps are maintained
with sufficient soft tissue to keep them as thick as possible to prevent devitalization of the skin.
If the head of the talus is prominent, a portion of this
bone can be removed in a beveled fashion by using an
oscillating saw and angling the blade 30 degrees from
distal proximal to plantar distal. The calcaneocuboid articulation is generally divided, but if part of the cuboid
can be maintained, this is preferable. Contouring the distal talus and calcaneus will help to decrease the size of
the stump, and this will help with prosthetic fitting.
The repair of the plantar soft tissue to the dorsal soft tissue is tenuous as there is no stout tissue dorsally to anchor
the plantar flap. For this reason, a myodesis is preferred;
it is performed by drilling holes in the distal talus and
residual cuboid and anchoring the plantar fascia to the
dorsal residual bone with 0 nonabsorbable suture. The
subcutaneous tissue is approximated with 3-0 absorbable
sutures and the skin repaired with 4-0 nylon suture.
The residual foot must be maintained in as much dorsiflexion as possible. To help achieve this, a rigid dressing
is applied by binding the residual foot from a proximalplantar to distal-dorsal direction and applying gentle but
firm compression on the residual foot. This rigid dressing
is applied and extended up to the proximal leg, maintaining the residual foot and ankle in a maximally dorsiflexed position to protect the repair.
CURETTAGE AND CRYOSURGERY OF THE CALCANEUS
■
■
■
A sciatic nerve catheter is used for intraoperative and
postoperative pain control. General anesthesia is used for
the procedure. The patient is placed into the lateral decubitus position with the affected side up. A tourniquet is
placed on the upper thigh. After sterile surgical preparation and draping, an L-shaped incision is made from the
tip of the fibula posteriorly and anterior to the Achilles
tendon. The incision is parallel to the fibula, extending
distally and making a curve at the border between the
dorsal and plantar skin of the calcaneus laterally.
The initial skin is incised using the scalpel and dissection
is carried down through the subcutaneous tissue. The
incision and approach are inferior to the peroneal tendons, which remain safely superior to the dorsal fasciocutaneous flap. The sural nerve is also more superior and
away from the operative field. The lateral wall of the calcaneus is exposed.
A corticotomy is made using a drill to open the lateral
wall of the calcaneus. The tumor is opened, which allows
for the curettage. Large curettes are used to remove the
obvious tumor material. This is followed by inspecting
and burring the edges of the remaining calcaneal wall.
Once the resection is completed, the cavity is irrigated to
again inspect the cavity for remaining tumor.
■
■
To do the cryosurgery, the tourniquet is inflated to 350
mm Hg. Gelfoam is used to line the skin edges and subcutaneous tissue around the wound site. The retractors are
placed over the Gelfoam, and laparoscopic tape sponges
are placed around the skin to cover the skin. The foot is
placed into a basin of warm water to try to keep the foot
warm to prevent any problems that the decreased temperature from the cryosurgery may cause in the uninvolved portions of the foot. Normal saline is poured into
the tumor cavity. Endocare cryosurgery probes are prepared on the back table. Ice balls are formed and noted at
the tip of each of the probes. Three- and 5-mm probes are
used for the cryosurgery. The cryoprobes are placed into
the tumor cavity and left in to complete a 10-minute cycle.
The skin is monitored for necrosis, and warm saline is used
to keep the skin warm and supple. The cavity is allowed to
thaw and the tourniquet is deflated.
The reconstruction portion of the procedure consists of
an allograft cancellous bone block from the bone tissue
bank that is cut and contoured and placed against the
subchondral surface adjacent to the subtalar joint. Two
small Rush rods are cut, contoured, and placed within
the calcaneus to extend from the subtalar joint, abutting and holding the allograft in place. PMMA is mixed
TECHNIQUES
■
through the interosseous membrane and reattached to
the neck of the talus with suture anchors or through a
hole drilled in the talus as described above.
An alternative solution is to place the posterior tibial
tendon through the interosseous membrane with the
medial half of the Achilles tendon. The Achilles tendon is
then suture-anchored to the neck of the talus and used
to augment the tibialis anterior or posterior tibial tendon. Achilles lengthening is also a helpful technique because it reduces the stress on the tibialis anterior. The
Achilles tendon is not necessary for normal ambulation
due to the lack of forefoot.
A long plantar flap is preferred, but if the tumor extends
into the plantar base and soft tissues, a fish-mouth incision is made with equal-length dorsal and plantar flaps.
To help prevent equinus contracture, the tibialis anterior
is detached from the tarsal navicular with a cuff of soft
tissue, preferably periosteum. A drill hole is made
through the neck and head of the talus in an oblique
fashion from dorsolateral to plantar-medial. The tendon
is then routed through this bone tunnel and sewn to itself or soft tissue as it exits through the tunnel. This repair may be augmented with bone anchors placed near
the dorsal opening of the tunnel.
The residual foot is maintained in maximal dorsiflexion
during this repair. Figure 2E shows the position of the
ankle after the amputation and reconstruction of the
tibialis anterior into the talus. Several additional procedures are required for a functional Chopart amputation.
Contracture prevention is critical and ensured through
transfer of the extensor tendons to the dorsum of the
foot and lengthening of the Achilles tendon.5
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TECHNIQUES
with 1 g vancomycin on the back table and prepared by
hand mixing. This is placed into the tumor cavity to fill
the cavity, completing the reconstruction. The midfoot
and forefoot are taken through gentle range of motion
to ensure normal movement of these joints and to
make sure that there was no iatrogenic extrusion of ce-
ment, which could compromise the motion of these
joints. Also, the calcaneus is gently axially loaded with
hand pressure to ensure that the reconstructed calcaneus moves as a single unit. A drain is placed, and the
wound is closed in layers. A plaster splint is used.
SYMES AMPUTATION
■
■
The incision extends from the anterior aspect of the lateral malleolus to the anterior aspect of the medial malleolus, continuing to the plantar skin. The incision at the
plantar flap is made to the level of the calcaneocuboid
joint. The soft tissues, including tendons, are incised and
allowed to retract; the neurovascular bundle is identified
and ligated. The talus and calcaneus are dissected sharply
and removed.
■
■
The surgeon must be cautious at the point of the Achilles
tendon insertion site: the skin is thin and adherent and
must be protected.
The flares of the malleoli are removed with a sagittal
saw. The plantar fat pad is fixed to the end of the stump
with nonabsorbable sutures into drill holes of the distal
tibia and fibula.
A drain is placed and the wound closed in layers; 3-0
nylon suture is used to repair the skin. A well-padded
soft dressing is applied.
PEARLS AND PITFALLS
Indications
■
A careful and complete history and physical examination are essential. Preoperative studies
are necessary to plan the resection and reconstruction.
Surgical incision
■
A long plantar flap results in a better end-bearing stump. The natural cascade of metatarsal
lengths should be maintained.
Wound healing complications
■
Local wound care with dressings and oral antibiotics are usually sufficient to allow for
healing.
Deep infection
■
Parenteral antibiotics and surgical débridement may be necessary to treat deep infections.
Early diagnosis and treatment can affect outcome.
Contractures
■
Postoperative splinting can help prevent contractures. Once a contracture occurs, it is
treated with stretching if mild. Serial casting may be needed.
POSTOPERATIVE CARE
Postoperative pain control will allow early mobilization of
the patient. Wound healing without complications and prevention of contractures, particularly equinus contractures, are
vital.1
■ For the Lisfranc and transmetatarsal amputations, a rigid
postoperative dressing is used. The wound is dressed with
nonadherent dressing gauze. A gauze roll is used to bind the
residual foot. Cotton padding is then placed in strips from the
hindfoot to the forefoot from plantar to dorsal in an attempt
to reduce the tension on the suture line. The heel is well
padded with cotton padding, and then a plaster cast is applied.
The cotton padding may have elastic in it for built-in stretch.
The plaster is also applied from proximal and plantar to distal
and dorsal to reduce the tension on the suture line. The plaster application should be firm but not tight. It should be placed
in closed-toe fashion and should extend up to the proximal
leg, maintaining the residual foot in the neutral position to a
slightly dorsiflexed position.
■ This initial dressing is changed after 3 to 5 days and the
Penrose drain is removed with the first dressing change. A similar plaster is applied for an additional 2 weeks. At the time of
■
plaster removal, the sutures are removed. The patient is given
a prescription for a shoe filler.
■ After 2.5 weeks, the patient’s foot is placed in a bucklewedge shoe for an additional 3 to 4 weeks. After that, shoe
wear and progressive ambulation are encouraged.
■ After a Chopart amputation, the cast is removed after 5
days and the drain is removed. A second dressing and cast are
applied for about 3 weeks. The second cast is removed and the
sutures are removed at the end of the 3 weeks. A third cast is
applied and maintained for 6 to 8 weeks. After the final cast is
removed, the patient begins physical therapy to begin range of
motion, in particular dorsiflexion and plantarflexion excursion of the residual foot. A prosthetic measurement is taken.
OUTCOMES
Patients with a Lisfranc, transmetatarsal, or Chopart amputation have good overall function compared with patients with
a Syme amputation.1,11,14 However, patients with an equinus
contracture after a Chopart amputation have inferior results.6,8
■ A Chopart amputation in a young patient is inferior in
function to a Syme amputation due to the lack of ability to
replace forefoot function when the space between the floor
■
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Chapter 42 FOOT AND ANKLE AMPUTATIONS: LISFRANC/CHOPART
and the plantar surface is reduced significantly in a Chopart
amputation.
■ The Chopart procedure provides an excellent level of amputation for a patient with limited activities and goals.1 The main
advantage to this level is that little is lost between the distal
end of the residual limb and the floor. This allows ease of ambulation without the need for a prosthetic device.13
■ For persons requiring short trips to the bathroom in the
middle of the night or stability for transfers, the Chopart level
is perfect. Unfortunately, the lack of anatomic structure and
minimal distance from the plantar surface to the floor makes
the Chopart amputation a poor choice for the active amputee.
■ Ambulation is achieved with a foot spacer. For the Chopart
stump, a clamshell type of prosthesis allows good weightbearing function and restores the effective foot length.4
■ Generally, patients are able to ambulate 3 months after
amputation using a simple shoe prosthesis.14
■ Gait analysis shows that abnormality and asymmetry of
ground-reaction forces were less with a greater preserved
stump length.9
COMPLICATIONS
Wound healing complications are treated with local wound
care, elevation, and non-weight bearing. Oral antibiotics may
be indicated. If there is skin flap necrosis, débridement with a
skin graft may be necessary.2
■ Superficial infection is often resolved with a short course of
oral antibiotics.
■ Deep infection may require immediate operative débridement of devitalized tissue. Parenteral antibiotics are important
to treat this limb-threatening problem. At the time of the
débridement, a bone culture should be ordered to help determine the appropriate antibiotic.
■ Equinus contracture is most easily treated by prevention.
However, stretching with a therapist may be helpful. Serial
casting may be required to correct the deformity.
■
9
REFERENCES
1. Berke GM. Lower limb prosthetics. In: Coughlin MJ, Mann RA,
Saltzman CL, eds. Surgery of the Foot and Ankle, 8th ed.
Philadelphia: Mosby, 2007:1399–1422.
2. Chang BB, Bock DE, Jacobs RL, et al. Increased limb salvage by the use
of unconventional foot amputations. J Vasc Surg 1994;19:341–349.
3. Chou LB, Malawer MM. Analysis of surgical treatment of 33 foot
and ankle tumors. Foot Ankle Int 1994;15:175–181.
4. Dillon MP, Barker TM. Can partial foot prostheses effectively restore
foot length? Prosthet Orthot Int 2006;30:17–23.
5. Garbalosa JC, Cavanagh PR, Wu G, et al. Foot function in diabetic
patients after partial amputation. Foot Ankle Int 1996;17:43–48.
6. Greene WB, Cary JM. Partial foot amputations in children: a comparison of the several types with the Syme amputation. J Bone Joint
Surg Am 1982;64A:438–443.
7. Hattrup SJ, Amadio PC, Sim FH, et al. Metastatic tumors of the foot
and ankle.Foot Ankle 1988;8:243–247.
8. Heim M. A new orthotic device for Chopart amputees. Orthop Rev
1994;23:249–252.
9. Hirsch G, McBride ME, Murray DD, et al. Chopart prosthesis and
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