Amputation of the forefoot_1

AMPUTATION OF THE FOREFOOT
Author: Luis Tapia Lazo
(Part One)
Clinical Podiatrist
The amputation may be a radical solution to a physiopathological process affecting
the member due to the lack of response to the medical and multidisciplinary
treatments or because of the aggression of the infection or traumatic process, and
the delay of some patients in the search of solutions, thus causing a complex or
necessary situation when deciding an amputation .
The forefoot presents the most frequent foot amputations because of two causes:
1. The vascular and infectious processes to be found so often in diabetic
patients
2. Dangerous traumatisms caused by accidents.
The forefoot amputations are well tolerated by the patient and the biomechanical
insufficiencies may be treated by not too complex orthopedic therapies.
It is important also to remember that an amputation at every level means a
surgery of vital importance determined by the aftermath orthotic devices.
If considering the foot as a balanced lever system it is necessary to maintain the
tendon balance at maximum , thus permitting a sufficient correct walking , avoiding
or minimizing secondary deformations, such as the acquired clubfoot, and the
building of hyperkeratosic zones, the most frequent results of the forefoot
amputation.
The excision level will be conditioned by the possibility of the stump being covered
with plantar skin at the support level, the only capable device to tolerate the
demands of the body weight. (fig. 9 and 10).
Amputation of the Toes
Fig.1 Archive
The amputation of the toes is very often provoked by a localized pathology (diabetic
foot- fig.1), and if the medical judgment considers trying to save the remaining
toes, at the same time it is possible having to face the fact that posterior situations
may advise the contrary.
The experience of many surgeons considers realizing a correct transmetatarsial
amputation rather than leaving behind nonfunctional, deformed , rigid and painful
toes.(fig.2)
Fig.2 Archive
Fig.3 Archive
Fig.4 Archive
The amputation of one or several toes determines three kinds of phenomena:
1.-The propelling power of the walk diminishes in proportion to the missing toes.
2.-The overburden of the involved metatarsian gives way to the total loss of the
propelling power at the beginning phase of the walk.
3.-The clinodactilia of the surviving toes , converging to the space left. (Valente
Valenti)
Amputation of one toe.
The amputation of one toe is the most invalidating because it rends difficult the
best development of the foot‘s toe- off , giving way to an insufficiency of the
propelling phase of the walk, varixating the foot, altering the internal longitudinal
arch and causing finally the overburden of the metatarsian heads of the remaining
radius.(Fig. 5,6 and 7: neuropathic ulcers).
Diagram of the most frequent amputations
Transmetatarsian Amputations
It is considarated the best tolerated by the patients and the most suitable by
the surgeons. It keeps the length of the limb and from the biomechanical point
of view , the toe off is not excessively compromised during the walk. The use of
prosthesis is easy and the plantar orthotic treatment is better tolerated. (Fig. 9
and 10).
Transmetatarsial
Amputation
technique.
Source: Orthotic
and prosthetic of
the walking
system
Fig.10 Archive
Orthotic treatment of diabetic patient with amputation of the 1st. toe
Silicon orthotic insole to compensate the missing of the amputated 3rd.
toe, thus avoiding the convergency of the 2nd.And 4th. Toe.
CONCLUSIONS
Statitics show that the percentage of amputation is 15 times higher in diabetic
patients than others. The incidence of contralateral amputation exceeds in
50% within the next 4 years after the first loss.
The amount of our action in the benefit of the patient with risk of amputation
must be the same as for the amputated one. Our first priority should be our
participation in the recovery of the foot`s function. We can use prevention
orthotic treatments of substantial effectiveness in our daily practice and try to
improve the education of our patients, in , at the same time, coordination with
the health staff.
It is our duty as health pros to understand the physiopathological and
biomechanical processes affecting the amputated foot.
¿How many amputations could be avoided with the help of a qualified
podiatrist?
Luis Tapia Lazo
Podólogo Clínico
BIBLIOGRAPHY
. Fig8. Orthotic and prosthesis of the walking system/ Inferior limb R. Viladot – O.Cohi –
S.Clavell.MASSON Ed. 1994
. Protocol in the diabetic foot Unity / Angel Camp Fauli – J:I:Mompo. Edited by the Podiatrist Federation
of Spain 1999.
.Orthotic of the foot /Valente Valenti Panamerican medical Ed.
. Podologo clinic archive Luis Tapia Lazo 2004 – 2005 Primary Health Care Antofagasta - Chile