Updated: 10/4/2016

Midfoot Amputation

Preoperative Patient Care

A

Outpatient Evaluation and Management

1

Obtain focused history and performs focused exam

  • evaluate
  • vascular status
  • if severe vascular dysfunction may require revascularization procedure prior to amputation
  • check with nutrition labs to evaluate wound healing potential
  • albumin
  • prealbumin
  • transferrin
  • total lymphocyte count
  • soft tissue injury
  • severe soft tissue injury has the highest impact on decision whether to amputate or reconstruct lower extremity in trauma cases
  • infection
  • CRP, ESR
  • neuropathy
  • trauma
  • vascular exam
  • Doppler (ischemic index)
  • ABI
  • transcutaneous oxygen pressure
  • toe pressures
  • need to assess associated injuries and comorbidities (diabetes)
  • documental baseline neurovascular exam
  • check plantar sensation
  • check dorsalis pedis and posterior tibial pulse

2

Appropriately interprets basic and advanced imaging studies

  • radiographs
  • weightbearing AP/Lat views of foot, ankle, and tibia/fibula
  • CT scan
  • bone sequestra
  • cortical destruction
  • MRI
  • look for integrity of soft tissue
  • infection
  • extent of neoplastic process
  • MRA and CT angiography
  • identifies level of arterial occlusion and whether surgical correction of the occlusion is warranted

3

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

4

Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound management
  • remove sutures on week three
  • nonweightbearing until wound is well healed
  • once healed can ambulate in well molded prosthetic device
  • diagnose and management of early complications
B

Advanced Evaluation and Management

1

Provides complex non-operative treatment

  • multiple co-morbidities
  • non-compliant
C

Preoperative H & P

1

Perform basic medical and orthopaedic history and physical

  • check neurovascular status to determine level of amputation

2

Appropriately order basic imaging studies

  • weightbearing images
  • AP/Lat views of foot, ankle, and tibia/fibula

3

Perform operative consent

  • describe complications of surgery including
  • infection
  • stump neuroma
  • wound breakdown (worse in diabetics, smokers, vascular insufficiency)
  • superficial and deep infections
  • phantom limb pain
  • skin ulceration
  • muscle imbalance
  • most common is equinovarus of the residual stump
  • dyvascular stump
  • bony exostoses

Operative Techniques

E

Preoperative Plan

1

Radiographic templating

2

Execute surgical workthrough

  • describes the steps of the procedure to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
F

Room Preparation

1

Surgical instrumentation

  • basic major orthopedic set
  • oscillating saw
  • amputation knife
  • silk free and stick ties
  • suction drain

2

Room setup and equipment

  • standard OR table
  • fluoroscopy

3

Patient positioning

  • place patient supine
  • place small bump under ipsilateral hip to internally rotate the leg
  • place a thigh tourniquet
G

Superficial Dissection

1

Trace the dorsal and plantar skin flaps

2

Make the skin incision

  • make a skin incision starting at the dorsomedial aspect of the foot at the midshaft level of the first metatarsal
  • continue the incision in a transverse manner along the dorsal aspect of the foot along the midshafts of the 2nd,3rd and 4th metatarsals
  • end the incision over the dorsolateral aspect of the midshaft of the 5th metatarsal

3

Continue incision medially

  • start incision from the medial aspect of the dorsal incision and continue it down to the level of the first metatarsal head

4

Make lateral incision

  • start incision from the lateral aspect of the dorsal incision and continue it down to the level of the first metatarsal head

5

Join incisions

  • curve both incisions in a plantar fashion
  • make a transverse incision on the plantar surface along the metatarsal heads
H

Deep Dissection

1

Dissect through underlying fascia

  • dissect through the subcutaneous tissue

2

Identify the neurovasculature

  • identify the dorsalis pedis artery and ligate
  • identify the peroneal and posterior tibial nerves
  • place gentle traction and resect nerves using sharp dissection
  • this prevents postoperative neuromas

3

Identify tendons

  • identify the flexor and extensor tendons of the foot
  • pull distally and perform sharp transection

4

Expose bone

  • use sharp dissection to create myocutaneous skin flaps

5

Maintain flaps

  • use an elevator to reflect tissues from the metatarsals proximally
  • reflect back to the level of the metatarsal shafts
  • make sure that the plantar flap is longer than the dorsal flap
I

Resect Bone

1

Resect metatarsal heads

  • use a small oscillating saw and transect heads at the level of the dorsal skin incision
  • transect the metatarsal heads in a dorsal distal to proximal plantar direction
  • preserve the peroneus brevis when resecting the 5th metatarsal head
  • bevel the resected ends of the 1st and 5th metatarsals
  • bevel medially and laterally
  • this is done to prevent skin ulcerations
J

Wound Closure

1

Prepare Flap

  • use sharp dissection to debulk the plantar flap

2

Irrigation, hemostasis and drain

  • irrigate with pulse irrigation
  • place drain

3

Deep closure

  • 0-vicryl for deep fascia
  • subcutaneous with 2-0 vicryl

4

Superficial closure

  • skin closure with 3-0 nylon (vertical/horizontal mattress)
  • soft incision dressing well padded to reduce pressure in incision

Postoperative Patient Care

O

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • IV fluids
  • pain meds
  • advance diet as tolerated
  • DVT prophylaxis
  • wound care
  • keep dressing on for 1 week
  • remove drain on POD 2
  • continue postoperative antibiotics until the drain is removed
  • appropriately orders and interprets basic imaging studies
  • inpatient pt
  • nonweighbearing
  • appropriate medical management and medical consultation

2

Discharges patient appropriately

  • pain meds
  • outpatient PT
  • wound care
  • schedule follow up in 2 weeks
R

Complex Patient Care

1

Develops unique, complex post-operative management plans

 

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