Proximal foot amputations

[heybrother]

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I'll leave this open ended - does anyone regularly (occasionally, ...ever) perform amputations proximal to a TMA/lisfranc. I'm of course interested in more than just a yes or no ie. talectomies, nails, fusions, etc.

I never saw this done during residency, nor did I see it done at any of the programs I visited. I'm trying to stay open to ideas outside of what my residency thought/taught.

 

[deleted285117]

Never seen or done. Essentially signing up someone for PTB brace forever until they (probably... eventually) just convert to BKA anyway.

But I too am curious if anyone else performs these?

 

[CutsWithFury]

I don’t go more proximal than a TMA. I’ve managed some symes amputations, done by other providers, in the wound care center. These patients are incredibly hard to offload and brace to prevent wounds once the fat pad atrophies. These patients would be better off with BKA in my opinion.

 

[Pronation]

How about ankle disarticulations as a staged procedure for someone else to do the BKA? Is this within scope anywhere?

 

[CutsWithFury]

How about ankle disarticulations as a staged procedure for someone else to do the BKA? Is this within scope anywhere?

It is within scope but WHY? I guess I would consider it if the infection was severe enough and needed to be dealt that day so it did not track up the leg.

Just seems like an unnecessary surgery and stress to the patient when it can be managed with a BKA.

 

[619]

It is within scope but WHY? I guess I would consider it if the infection was severe enough and needed to be dealt that day so it did not track up the leg.

Just seems like an unnecessary surgery and stress to the patient when it can be managed with a BKA.

I agree. Ankle disarticulations should be done in very rare situations (even then an I&D or open fasciotomy will be adequate if BKA is not available rather an ankle disarticulations) when the infection is rapidly spreading and the podiatrist is the only surgeon available. But we know this is most never the case except in a small hospital in the middle of no where. Even in the smallest hospital, there is always a general surgeon or general orthopedist available who perform BKAs.
In recent years, vascular surgeons have been the to-go for BKA since they also re-vascularize the patient. However a lot of rural places still have the general surgeon or general orthopedist regularly perform the BKAs.

 

[AttackNME]

Anything proximal to a tma is difficult to manage for most patients, especially chopart, which isn’t better than a prosthesis and a bka, but with that said I’ll still do them on very select patients and after a lot of education.

 

[SouthPod7]

Anything proximal to a tma is difficult to manage for most patients, especially chopart, which isn’t better than a prosthesis and a bka, but with that said I’ll still do them on very select patients and after a lot of education.

Do you routinely do any tendon transfers if you are going proximal to TMA? Like PB for LisFranc's?

 

[AttackNME]

Do you routinely do any tendon transfers if you are going proximal to TMA? Like PB for LisFranc's?

Sometimes tal, and pb to cuboid, but no other prophylactic transfers, I think a lot of these patients are likely to die before they reulcerate, so I’ll address the biomechanics if it poses a problem

 

[dtrack22]

Anything proximal to a tma is difficult to manage for most patients, especially chopart, which isn’t better than a prosthesis and a bka, but with that said I’ll still do them on very select patients and after a lot of education.

Yup. There are select patients who you know will never get a prosthetic (for a variety of reasons), and something like a chopart might be keeping them more functional and independent than a BKA. Independent self care is very important and often too “small picture” for a lot of podiatrists to worry about. Meaning, neither the BKA patient (w/o prosthesis) nor the chopart patient are walking, so you think “what to they need their distal leg for?” But the latter may be less likely to need a caregiver for simple things like bathing, simply because he/she has an easier time independently transferring.

I think those who have failed a TMA/Lisfranc or have pathology proximal to that and are better off with a chopart (for example) are a very small minority, but I believe they exist.

I’ve never done anything other than chopart, in terms of being proximal to lisfranc.

 

[Halux]

I have done a fair amount of chopart amputations (always transfer PB/AT and TAL), In residency we did one pirogoff and he did quite well. Did a few talectomies but those almost always went on to BKA. I did a good amount of training at a big kaiser hospital and if it was a vascular problem then vascular would do BKA and they were really good about it. If it was infection though then ortho would handle it and they would avoid doing anything like it was COVID!!! So we ended up dis articulating a lot more ankles than we would like because of gas gangrene. I once had an ortho tell me that the gas at the proximal tib-fib joint was free air from a wound on the dorsolateral foot (Bahaha).

I think the big point is to tell patients that afterwards they aren't going to walk but be able to transfer to a wheel chair easily and maybe take a few steps but that's it.

 

[PeaJay]

I haven’t done any on my own, but in residency we would do ankle disarticulations to stage for bka. It was Vascular's preference in many instances. Also very selective use of chopart with a closed nail or balancing.