Diabetes

Question 1

20% incidence of re-amputation
following ANY loss of first ray integrity
within

Answer 1

1 year

Question 2

Diabetic Foot Triad

Answer 2

Impaired Wound Healing
–Trauma
–Deformity

Question 3

Impaired Wound Healing

Answer 3

Uncontrolled hyperglycemia - Immune system dysfunction
* Peripheral artery disease – Ischemia
* Infection
* Chronic/Necrotic/Senescent tissue load – Serial debridement

Question 4

Trauma

Answer 4

Sensorimotor neuropathy
* Not just sensory!
* Motor: Leads to deformity
* Autonomic: Sweat gland dysfunction
* Fat pad and skin changes

Question 5

Deformity

Answer 5

Structural Deformity leading to increased pressure
*Both static and dynamic contributions
–External “off-loading”
–Internal “off-loading”

Question 6

Intrinsic muscle wasting
secondary to sensorimotor
neuropathy

Answer 6

The motor nerves supplying the
intrinsic foot musculature are the
longest and smallest nerves in the
body.
the long flexor and extensor
tendons overpower these
intrinsics…
– Ergo….the toes pop up and
metatarsal heads pop down.

Question 7

Intrinsic muscle wasting
secondary to sensorimotor
neuropathy
– Increases deformity and pressure to the
forefoot, specifically the

Answer 7

plantar
metatarsal heads, dorsal proximal
interphalangeal joints, and distal
digital tufts.

Question 8

Deformity/pressure lead to

Answer 8

callusulcerationinfectionamputation

Question 9

Tendon
glycosylation
leading to equinus

Answer 9

The Achilles is the
largest and thickest
tendon, so is the most
affected by this
process.
– Produces additional
pressure on the plantar
forefoot.

Question 10

We can….
* Just resect what is dead,
or

Answer 10

Resect at a functional
level of amputation and
plan for complications.

Question 11

Functional level of
amputation: hallux

Answer 11

Leaving the base of the
proximal phalanx intact
– Obliquely across the first
metatarsal.

Question 12

Leaving the base of the
proximal phalanx intact

Answer 12

eaves the attachment of the
abductor hallucis, adductor
hallucis, flexor hallucis
brevis and extensor hallucis
brevis.
– Provides a buttress for the
2nd toe to prevent deviation.

Question 13

Obliquely across the first
metatarsal.

Answer 13

Can utilize the abductor
hallucis muscles for closure.
– Maintains tibialis anterior
and peroneus longus
tendinous insertions.

Question 14

Expected complications:Hallux and First Ray Amputations

Answer 14

Lesser digital gripping.
– Increased load on the 2nd MPJ.
– Loss of propulsion.
– Medial column instability
loses
its compensation resulting in
increased pressure on the
lateral column.

Question 15

External Off-Loading”

Answer 15

Insert with a toe filler.
–Extra-depth multi-density
insert.
–Rocker bottom soled shoe.
–Increased rearfoot
stability with a deep heel
cup and ankle support.

Question 16

Hoke Triple Hemisection:

Answer 16

3 stab incisions up the
Achilles tendon (2 lateral,
1 medial or vice-versa).

Question 17

Lesser Toe AmputationsI can potentially prevent
residual deformity by:

Answer 17

Leaving the base of the
proximal phalanx when
possible.
– Evaluate the other digits for
flexible/rigid deformity with
performance of flexor
tenotomies as needed.

Question 18

Transmetatarsal
amputation:

Answer 18

Resection of all 5
metatarsals at some point
within the shaft.
–Generally considered to
be a very “durable”
procedure.

Question 19

Transmetatarsal AmputationsAttempt to
preserve a nice

Answer 19

“parabola” of
the metatarsals
following
resection.

Question 20

ransmetatarsal
amputation function:

Answer 20

Extensor hallucis longus
– Flexor hallucis longus
– Extensor digitorum longus
– Flexor digitorum longus
– Tibialis anterior
– Peroneus longus
– Peroneus brevis
– Tibialis posterior
– Achilles tendon

Question 21

Balancing the TMA: Sagittal Plane: plantarly too much oull, not enough dorsal balance of muscles. solution?

Answer 21

Hoke Triple Hemisection:
-3 stab incisions up the Achilles
tendon (2 lateral, 1 medial or vice-
versa).
Gastroc Recession:
-Transverse cut across the
gastrocnemius aponeurosis.

Question 22

Balancing the TMA: Frontal Plane

Answer 22

Inversion Vector:
-Tibialis Anterior tendon
-Posterior Tibial tendon
-Achilles tendon

Question 23

Balancing the TMA: Frontal Plane

Answer 23

Eversion Vector:

Question 24

Frontal Plane
Tibialis Anterior Lengthening

Answer 24

Describe a z-
lengthening of
the tibialis
anterior tendon
for forefoot
varus.

Question 25

Transmetatarsal Amputations

Answer 25

Lose considerable
propulsion at the ankle
with loss of metatarsal
heads and (often) a TAL.
–Hip becomes much more
important driver of
forward propulsion.

Question 26

Midfoot and Rearfoot Amputations

Answer 26

Once proximal to the
tarsometatarsal level, the
Achilles and PT are the only
tendons left:
– Need an intact calcaneal fat pad
– Need normal subtalar joint ROM
* Not considered a functional
level of amputation.
* Need an appropriate brace.