surgical techniques of hallux amputation - The Podiatry Institute

CHAPTER 37 205
POSTOPERAITVE MANAGEMENT
Most postoperative regimes following halh:x
amputation initially require strict non-weight bearing
of the involved extremily. It is important for the
podiatric surgeon to not neglect the contralateral
1imb, which is at increased risk. This requires
frequent monitoring and protective measures. The
use of the Cam walker is an excellent regime to
progress from a non-weight bearing to a pafiial
weight bearing status. The Cam walker can be used
effectively until it is appropriate to advance to the
use of a shoe. An extra depth shoe with a prescribed
plastizote medial forefoot filler and inlay, combined
with a rigid shank is recommended for ambulation
following successful healing. The use of a neutral
position ofihotic device with intrinsic forefoot
posting helps to control the potential postoperative
forefoot varus position following hallux amputation
surgery.
Historically, diabetic patients presenting with a
foot r:lceration would have had an amputation at a
proximal level because of the assumed inabiliry to
heal at the level of distal amputations. \7hen an
infection has involved the plantar spaces of the foot,
it has been believed that the only hope of saving the
patient's limb was to perform a guillotine
amputation of the affected limb. \(hen a
neurotrophic diabetic patient presents with foot
ulcerations, it is not always necessary to perform a
proximal amputation. Partial forefoot amputations
such as a hallux amputation a1low the minimum
possible amputation at the lowest level with a major
advantage of the ability to bear weight.
BIBLIOGRAPHY
Bilk D. Selby JV, et al: Lower extremity amputations in people u'ith
cliahetes: epidemiology and prevention. Diabetu Care 1,990:73:573.
Chang B, Bock D, Jacobs R, Darling R, Leather R. Shah D. Increased
limb sah'age by the use of unconventional fbot amputations. Jr
V as c S urg 7994;79 :347 -9.
Downs DM, Jacobs RL. Treatment of resistant ulcers on the plantar
surfhce of the gleat toe in diabettcs. J Bone Jaint Swg Am
7L)82:64:930-3.
Duggar. GE, et a1, Time-Line for the diabetic frrot. In: McGlamry ED.
editor. Podiatry Instltute Update 1987. Tucker (GA): Podiatrl,=
Institute Publishing; 1987.
Fronek A, Coel M, Bernstein EF. The impofiance of combined muitisegmental
pressllre and Doppler flon' r'elociqv stuclies in the
diagnosis of peripheral arterial occlusive disease. Sarxerl'
1978;8'1:840-7.
Gavin, LA. Perioperative management of the diabetic patient:
enclocrinology and metabolism Clin N Am 7L)92;21:157-75.
Goldstein B, Citron D, Neshit C. Diabetic foot infections. Diabetes Care
7996;79:638-41.
Griffiths, GD, \i7ieman, TJ. N,{eticulous attention to foot crre impror-es
the prognosis in diabetic ulceration of the foot. Surgerl Gyn Obst
7992:174:19 51.
Lance B, Kirschenbaum S. Distal ischemia s'ith digital gansirene sec
ondary to buerger's clisease../ Faot Sarg 1991;30,531 17.
Levin M. Foot lesions in patients w-ith cliabetes mellitus. Cbron Comp Diab
7996;25'147-55.
Levin ME, O'Neil L\Xr. The Diabetic Foot. St. Louis: CV Nlosb-v; 1!88. p.
77.
Pinzur NIS, Gold J, SchnartT- D, et al. Energv demands for u'alking in
d\rsvascular xmplltees as related to the level ot.L]nlputetion. OrtbLl)
199275:1033-1 .
Pinzur MS, Sage R, Abral'ram NI, et al. Limb salvage in inf'ectecl lori-er
extremity gangrene. Foot Ankle 1988:8:212-5
Sizer JS,
\Mreelock FC. Digital amputations in diabetic patients. SzzrgerT
7972:i2:L)80-9.
litti M. Robinson D, Hauer-Jensen M, Thompson B. Ranval T, Barone
G, et a1. Vound healing in fbrefoot amputations: the predrctive
r:lrre of 1,,( fre