From the Guidelines
Midfoot amputation should be considered as a last resort for patients with severe diabetic foot infections or trauma, prioritizing limb salvage and multidisciplinary care to minimize morbidity, mortality, and improve quality of life. When midfoot amputation is necessary, the procedure involves removing a portion of the foot through the midfoot region, typically performed to address severe infection, trauma, or vascular disease affecting the forefoot that cannot be salvaged 1. The goal of this procedure is to preserve the heel and ankle function while removing the diseased or damaged portion of the foot, thereby maintaining reasonable mobility with appropriate rehabilitation and prosthetic support.
Pre-Operative Considerations
Before proceeding with midfoot amputation, it is essential to ensure that all other treatment options have been exhausted, and the patient has received optimal medical and surgical management, including antibiotic therapy, debridement, and wound care 1. A multidisciplinary foot care team, comprising professionals with specialist skills, should evaluate the patient's response to treatment and determine the need for surgical intervention.
Post-Operative Care
Post-operatively, patients require wound care with daily dressing changes using sterile technique and normal saline or prescribed antimicrobial solutions. Pain management typically includes acetaminophen 650mg every 6 hours and tramadol 50mg every 6 hours as needed for the first week, then tapering as tolerated. Physical therapy should begin within 1-2 weeks after surgery, focusing initially on non-weight bearing exercises and progressing to partial weight bearing with assistive devices.
Rehabilitation and Follow-Up
Patients will need custom footwear or prosthetics fitted approximately 6-8 weeks after surgery when the wound has adequately healed. Complications to monitor include infection (signs: increased pain, redness, warmth, drainage), wound dehiscence, and phantom limb pain. Regular follow-up appointments are essential at 1 week, 2 weeks, 1 month, and 3 months post-surgery to ensure proper healing and functional recovery.
Key Considerations
- Multidisciplinary care is crucial in managing diabetic foot infections and preventing amputations 1.
- Limb salvage should be prioritized whenever possible, and amputation should be considered a last resort.
- Patients with diabetes require education on foot care and prevention of foot ulcers to reduce the risk of complications.
- Custom footwear or prosthetics can significantly improve mobility and quality of life for patients who have undergone midfoot amputation.
From the Research
Mid Foot Amputation Overview
- Midfoot amputations are viable options for limb preservation in cases of forefoot infection, diabetic ulcers, critical limb ischemia, trauma, or malignancy to avoid major lower-extremity amputation 2.
- Each level of midfoot amputation has limitations to consider, including wound healing problems, soft-tissue contracture, or need for revisional amputations 2.
Benefits and Considerations
- Midfoot amputations have benefits as viable options for limb and functional preservation and to avoid major limb amputation 2.
- The decision on the level of midfoot amputation is determined by multiple factors, including degree of tissue loss, vascular status, the ability to preserve function, surgeon experience, and pertinent patient factors 2.
- A good foot stump permits full end bearing and enables the patient to walk without the need for a prosthesis, with the more peripheral the amputation level selected, the greater the need for gentle tissue handling and meticulous postoperative care 3.
Surgical Techniques and Outcomes
- Surgical techniques for midfoot amputations include the use of a long plantar flap, resection of metatarsal and midfoot bones, and preservation of the toes and their neurovascular supplies 3.
- The "hidden" amputation, which involves resection of metatarsal and midfoot bones without removing the toes, is a viable option that preserves the length of the stump and minimizes the loss of weight-bearing surface 3.
- Studies have shown that midfoot amputations can be successful in preserving limb function and avoiding major limb amputation, with some patients able to walk barefoot over short distances after surgery 4.
Postoperative Care and Rehabilitation
- Postoperative care for midfoot amputations includes wound debridement, open wound treatment, and delayed primary closure, with full plantar weight bearing in a plaster cast or walker possible 4-6 weeks after surgery 3.
- Rehabilitation after midfoot amputation involves the use of a total contact prosthesis or orthopedic footwear, with the goal of maintaining the greatest length possible and minimizing wound healing disorders 3.
- Studies have also investigated the optimal duration of antibiotic therapy after surgical amputation in diabetic foot infections, with some findings suggesting that antibiotics can be discontinued immediately after surgery without increasing the risk of clinical failure 5.