What are the considerations for a bilateral midfoot amputation in an elderly patient?

From the Guidelines

Bilateral midfoot amputation in elderly patients should be approached with a comprehensive management plan prioritizing morbidity, mortality, and quality of life, and I recommend a multidisciplinary team management including a vascular surgeon, orthopedic surgeon, rehabilitation specialist, wound care specialist, and prosthetist. The surgical procedure typically involves transmetatarsal amputation with preservation of the heel pad when possible, as minor amputation, usually up to the forefoot, is often needed for necrotic tissue removal with minor impact on patient mobility 1. Post-operatively, pain management should include multimodal analgesia with scheduled acetaminophen and gabapentin, and short-term opioids as needed. Wound care involves regular dressing changes with antimicrobial dressings and offloading pressure.

Some key considerations in the management of bilateral midfoot amputation in elderly patients include:

• Pre-amputation revascularization to enhance wound healing, although primary major amputation without revascularization may be preferable in cases of extensive necrosis or infectious gangrene 1
• The potential benefits of below-the-knee (BTK) amputation, which allows better mobility with a prosthesis, although above-the-knee amputation may be the preferred choice for bedridden patients 1
• The importance of shared decision making with patients regarding consideration for amputation, taking into account patient physiology and mortality risk 1
• The need for long-term clinical follow-up to assess the need for and adequacy of prosthetic or orthotic devices, and to improve functional outcomes 1

Elderly patients face unique challenges including longer healing times, higher risk of complications, and potential difficulties with prosthetic adaptation due to decreased strength and balance. Nutritional support with protein supplementation and adequate caloric intake promotes healing. Regular follow-up appointments should occur weekly initially, then biweekly to monthly as healing progresses, to monitor for complications such as wound dehiscence, infection, and phantom limb pain.

From the Research

Bilateral Midfoot Amputation in the Elderly

• Bilateral midfoot amputations can be a viable option for limb preservation in elderly patients with conditions such as forefoot infection, diabetic ulcers, critical limb ischemia, trauma, or malignancy 2.
• The level of midfoot amputation is determined by multiple factors, including degree of tissue loss, vascular status, ability to preserve function, surgeon experience, and patient factors 2.
• Custom dynamic orthoses and physical therapist intervention can improve gait, mobility, and quality of life in elderly patients with bilateral midfoot amputations 3.
• Partial foot amputations, including midfoot amputations, can be feasible in elderly patients, with a good foot stump permitting full end bearing and enabling the patient to walk without a prosthesis 4.
• Elderly patients with amputations often face unique challenges, including comorbidities, general deconditioning, and lack of social support, which can affect postoperative care and rehabilitation 5.
• Gait abnormalities are common after amputations in diabetic patients, and soft tissue balance is key to maximizing gait and preventing deformities such as equinus and equinovarus 6.
• Orthotic, prosthetic, and shoe modifications can help minimize gait abnormalities in elderly patients with bilateral midfoot amputations 6.
• A multidisciplinary approach to care, including early involvement of physiatrists, can result in more favorable outcomes for elderly patients with bilateral midfoot amputations 2, 5.