From the Guidelines
Dorsal flap foot amputation is a viable surgical option for severe foot infections, gangrene, or trauma, and is preferred due to its potential for improved healing outcomes and reduced risk of breakdown at the amputation site. When considering a dorsal flap foot amputation, it is essential to weigh the potential benefits against the risks, including the possibility of infection, wound breakdown, and the need for ongoing care and rehabilitation 1. The procedure involves creating a flap from healthy dorsal tissue, removing the diseased portion of the foot, and then folding the flap over the wound for closure.
Post-Operative Care
Post-operative care is crucial to ensure proper healing and prevent complications. This includes:
- Elevation of the extremity for 24-48 hours to reduce swelling
- Regular dressing changes with sterile technique to prevent infection
- Prophylactic antibiotics, such as cefazolin 1-2g IV every 8 hours for 24-48 hours, to prevent infection 1
- Pain management with medications like oxycodone 5-10mg every 4-6 hours as needed
- Thromboprophylaxis with enoxaparin 40mg subcutaneously daily to prevent blood clots
Rehabilitation and Follow-Up
Physical therapy should begin within days of surgery to prevent contractures and maintain strength. Patients should be monitored for signs of infection, including increased pain, redness, warmth, drainage, or fever, which would require prompt medical attention 1. The presence of limb or foot ischaemia has an important adverse effect on the outcome, synergizing with infection to worsen the prognosis 1.
Outcome and Prognosis
In the hands of an experienced surgeon, most amputations can be foot sparing, and long-term control of infection is achieved in over 80% of cases 1. However, the presence of gangrene or osteomyelitis and a wound area of >5 cm2 are independent risk factors for amputation 1. Factors that predict healing include the absence of any exposed bone, palpable pedal pulses, blood pressure in the toe of >45 mmHg or in the ankle of >80 mmHg, peripheral white blood cell count of <12,000/mm3 and a lower extremity transcutaneous oxygen tension of >40 mmHg 1.
From the Research
Dorsal Flap Foot Amputation
- A dorsal flap foot amputation involves the removal of a portion of the foot, with the creation of a dorsal flap to cover the remaining stump 2.
- The goal of this procedure is to preserve as much of the foot as possible, allowing for full end bearing and enabling the patient to walk without the need for a prosthesis.
- The procedure typically involves a long plantar flap that covers the bones and is sutured to a short dorsal flap at the dorsum of the foot.
Surgical Technique
- The surgical technique for a dorsal flap foot amputation involves making a dorsal incision down to the bones, followed by the separation of the bones and the creation of a plantar soft tissue flap 2.
- The bones are then well aligned and shaped, and the dorsal flap is sutured to the plantar flap.
- Longitudinal amputations are preferred, as they preserve a larger load-bearing surface.
Postoperative Care
- Postoperative care for a dorsal flap foot amputation typically involves wound debridement, open wound treatment, and delayed primary closure in the case of infection 2.
- Full plantar weight bearing in a plaster cast or walker is possible 4-6 weeks after surgery.
- Total contact prosthesis without limiting the range of motion of the ankle and subtalar joint can be used after 6 weeks.
Alternative Procedures
- Alternative procedures to dorsal flap foot amputation include the use of fillet flaps, which can be used to reconstruct complex defects resulting from tumor and trauma 3.
- Fillet flaps can be used as pedicled or free flaps and can be a beneficial reconstruction strategy for major defects.
- Another alternative is the use of a "hidden" amputation, where the bones are resected without removing the toes, resulting in a more acceptable appearance for the patient 2.