Level
Level not predicated by angiography
- best is appearance of ST at time of surgery as judged by experienced surgeon
Toe
Technique
- dorsal-plantar or side-to-side flap
- tension free closure
- high reamputation rate in PVD / DM
Hallux
Technique
- stabilise sesamoids in hallux amputation
- leave base of P1 to prevent adjacent toes falling into gap
- this also preserves plantar fascia
- tenodesis of FHB
Second Toe
- beware of HV postoperatively
- can use insert
- may need to fuse 1st MTPJ
Ray
Indications
- single medial or lateral ray that has an infected ulcer
- multiple resections may excessively narrow foot
- central ray amputations are inferior to Lis Franc amputation
Technique
- racquet shaped incision based on involved MT to avoid NV bundles
- most are partial ray resections
- leave base
Prosthesis
- Oxford extra-depth shoes with custom insoles
Lisfranc
Technique
- at TMT
- create long plantar flap
- smooth curve fashioned
Precautions
- muscle balance
- Tendo achilles lengthening may be required to avoid later equinus
- muscle reattachment especially Peroneus brevis (try to preserve base fifth MT)
Prosthesis
- may initially require AFO
- usually shoe filler eventually
Chopart
Concept
- excellent amputation
- through midfoot leaving only talus and calcaneum
Advantage over Symes
- no problems with heel pad migration
- functional end bearing stump
- no LLD
Technique
- original procedure without transfer had problems with late equinus & varus
- reattach to talus neck T. Ant / T Post / EHL / EDL
- Tendo achilles lengthening
Prosthesis
- AFO with foot plate & filler
- slipper style prosthesis
Boyd
Concept
- talectomy / forward shift of calcaneum / calcaneotibial arthrodesis
Advantage over Symes
- preserves length & growth centres
- no heel pad migration
Disadvantage
- bulky stump
- poorer cosmesis
Technique
- dorsal incision from tip LM to 1 inch below MM
- planter incision transversely across sole at level MT bases
- amputate forefoot through Chopart joint
- excise talus
- anterior calcaneal osteotomy transversely across calcaneum at level of peroneal tubercle
- shift calcaneum anteriorly
- excise cartilage of distal tibia / fibula & superior calcaneum
- calcaneo / tibial arthrodesis
- steinman pin through calcaneum and tibia
- close over drains
Pirigoff
Concept
- talectomy
- anterior 1/2 calcaneum excised
- rotated 90°
- calcaneo-tibial arthrodesis
- used in children to preserve length & growth centres
Symes
Principle
- through ankle joint
- may allow ambulation with out prosthesis in emergencies
- end-bearing with stable gait pattern
- can still fit ankle prothesis
- women can be unhappy with cosmesis
Technique
- from tip of LM to 1 inch below tip MM across front of ankle
- then continue plantarward under sole between same points / MT bases
- need to preserve large post heel pad
- excise talus & calcaneus
- remove malleoli at level of joint & contour
- divide arteries / veins / nerves above levels of flaps
- anchor heel pad to anterior tibia via intra-osseous sutures
Problems
- heel pad migration is biggest complication
- don't trim dog ears or can get skin slough