From the Guidelines
A dorsal flap forefoot amputation should be considered as a last resort for severe forefoot infections, gangrene, or vascular insufficiency that cannot be managed with more conservative treatments, prioritizing preservation of tissue and function. When deciding on the surgical approach, it is crucial to consider the anatomy of the foot and the ways in which infection spreads through its fascial planes 1. The goal of surgical treatment is to drain any deep pus, minimize tissue necrosis, and remove devitalized and infected tissue.
Key Considerations
- The procedure involves creating a flap of skin and soft tissue from the top (dorsal) surface of the foot to cover the amputation site, which helps in preserving as much length as possible.
- The surgeon should aim to preserve blood supply to the flap and remove the affected bones (typically metatarsals) to promote healing.
- Post-operative care is critical and includes elevation of the extremity, regular dressing changes, and administration of appropriate antibiotics if infection was present.
- Pain management and physical therapy are also essential components of the post-operative care plan.
Surgical Approach
The surgical approach should be carried out by a surgeon with thorough knowledge of the anatomy of the foot, as the relationship between the point of entry of an infection and the compartment in which the infection spreads is crucial in determining the extent of the surgery 1. The aim is to provide a more functional foot, and bone resection and amputation are often necessary when there is extensive soft tissue necrosis.
Post-Operative Care
Post-operative care includes elevation of the extremity for 24-48 hours, regular dressing changes using sterile technique, and administration of appropriate antibiotics if infection was present. Pain management typically involves opioid medications initially, followed by transition to non-opioid analgesics. Physical therapy should begin within 1-2 weeks post-surgery to maintain mobility and strength. The advantage of this technique is the preservation of heel-bearing function and a more cosmetically acceptable result compared to more proximal amputations, while providing durable soft tissue coverage with well-vascularized tissue to promote healing 1.
From the Research
Dorsal Flap Forefoot Amputation
- A dorsal flap forefoot amputation is a surgical procedure that involves the removal of a portion of the foot, with the creation of a dorsal flap to cover the wound 2.
- The procedure is often performed to treat conditions such as peripheral vascular disease, diabetes, and infections 2, 3.
- The goal of the procedure is to preserve as much of the foot as possible, while also ensuring that the wound is covered and can heal properly 2.
Surgical Technique
- The surgical technique for a dorsal flap forefoot amputation typically involves making an incision on the dorsal surface of the foot, and then dissecting the tissues to create a flap that can be used to cover the wound 2.
- The flap is usually created from the dorsal skin and subcutaneous tissue, and is designed to be long enough to cover the entire wound 2.
- The use of a medial forefoot fillet flap has also been described as a technique for covering large wounds after partial forefoot amputation 3.
Postoperative Care
- Postoperative care for a dorsal flap forefoot amputation typically involves immobilization of the foot in a cast or splint, and the use of antibiotics to prevent infection 2.
- The wound is usually left to heal by secondary intention, or may be closed with sutures or staples 2.
- The use of negative pressure wound therapy (NPWT) has also been described as a technique for promoting wound healing after forefoot amputation 4, 5.