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25 Prosthetics, Orthotics, andAmputation Rehabilitation
355
Table 25.1 Medicare functional classication levels for
amputees, updated January 2020 [39]
K-level Description
K-0 Does not have the ability or potential to
ambulate or transfer safely with or without
assistance and a prosthesis does not enhance
their quality of life or mobility
K-1 Has the ability or potential to use a prosthesis
for transfers or ambulation on level surfaces at
xed cadence. Typical of the limited and
unlimited household ambulator
K-2 Has the ability or potential for ambulation
with the ability to traverse low level
environmental barriers such as curbs, stairs, or
uneven surfaces. Typical of the limited
community ambulator
K-3 Has the ability or potential for ambulation
with variable cadence. Typical of the
community ambulator who has the ability to
traverse most environmental barriers and may
have vocational, therapeutic, or exercise
activity that demands prosthetic utilization
beyond simple locomotion
K-4 Has the ability or potential for prosthetic
ambulation that exceeds basic ambulation
skills, exhibiting high impact, stress, or energy
levels. Typical of the prosthetic demands of
the child, active adult, or athlete
The utilization of a preparatory prosthesis
affords a patient the opportunity to assess their
long-term desires and true functional goals. For
example, a patient might exhibit a need for
increased activity, ability to ambulate with variable cadence, and encountering uneven terrain—warranting an upgrade in componentry,
thereby changing the K-Level from K2 to K3
(Table 25.1). Another patient might have an
early goal of high activity, e.g., playing basketball on a dynamic foot. However, through the
initial ambulatory timeframe, this primary goal
might evolve into a desire to navigate inclined
terrain, necessitating a different ankle design
with increased range of motion through articulation. Further physical, occupational, or psychological therapy might be needed to improve
strength, balance, and condence. In conjunction with a more dened physiological outcome,
early ambulation can aid the reduction of the
$327 billion diabetic related annual health care
costs [2, 29].
Denitive Prosthesis
Limb maturation occurs from 1 to 12 months
post-operatively, at which point the limb volume
has relatively stabilized [40, 41]. Skin tolerance
toward bearing weight and pressure has improved.
Functionality and long-term goals have been
assessed. This period of time is ideal to provide a
denitive prosthesis to the new amputee.
A denitive lower extremity prosthesis is
designed for use over the next several months or
years barring any substantial physiological or
functional changes. It is inclusive of several components: suspension, socket, pylon, foot. For
more proximal amputation levels, a knee or hip
joint might be needed.
Suspension: A means to attach the prosthesis
to the limb. Commonly used interfaces are gel
liners. They create a high level of friction against
the skin in order to suspend the prosthesis with a
pin attachment or through a suction seal. The gel
also creates a level of cushion around the limb,
absorbing impact and assisting with pressure distribution. In addition, liners add a level of compression to the skin to contain shape and volume
enhancing prosthetic control. Anatomical contours over boney prominences, skin t, waist
belts, or other strap mechanisms are also viable
means of suspension.
Socket: The highly customized portion of the
prosthesis that encompasses the limb. The
socket is derived from an impression of the
patient’s limb and modied for an intimate t.
The goal is to optimize pressure distribution
which enhances control of the prosthesis,
reduces unnecessary energy consumption, and
distributes oor reaction forces against the limb
to mitigate skin breakdown. Typically fabricated
out of polymers or carbon ber to reduce weight
and material thickness while maintaining integrity and durability.
Pylon: The segment of the prosthesis that connects the socket or knee to the foot made of a
lightweight aluminum, titanium, or carbon material. A pylon enables adjustability for the prosthesis, ensuring the foot position relative to the
socket, knee, and hip is in an inherently stable
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orientation. It allows for rapid and precise
changes to height and alignment based on patient
presentation to optimize their gait pattern for efciency, reducing energy consumption and fall
risk. Contracture accommodation may be necessary to maintain balance, stability, and posture
and is further accomplished with the modular
nature and versatility of the pylon.
Foot: The most dynamic aspect of the prosthesis. The foot connects the prosthesis to the
ground. There are a wide range of designs dependent on a patient’s functional needs. Entry level
SACH (solid ankle, cushion heel) feet provide
basic needs for standing, transfers, and single
cadence ambulation. Enhanced designs include
energy storing feet with carbon springs that
deect and roll under pressure. Articulating
ankles add hydraulic chambers to further control
motion through dampening resistance.
Microprocessor controlled articulating ankles are
able to change dorsiexion and plantarexion
hydraulic chambers independently and can have
a marked improvement on balance and better
mimic biological gait [42]. Self-powered ankles
add motors to replace the missing gastrocnemius
complex. This active design has been shown to
reduce energy consumption, however, remains
bulky and costly [43]. The overall goal of a foot
is to provide a uid motion to mimic the anatomical foot for balance, stability, and function.
The dynamic nature of the human body
ensures that limb shape and volume are under
constant change, even after reaching limb maturation. Volume changes occur through the day.
External limb pressure from the socket during
ambulation causes volume loss. Alleviating this
pressure upon prosthesis removal results in limb
volume increase. Compression is also utilized at
night or when not using the prosthesis to mitigate
the uctuation, but a discrepancy will persist.
Dietary choices can impact limb volume uctuation. Patients on dialysis undergo extreme volume changes between dialysis appointments
[41]. Long-term changes occur due to muscle
atrophy, activity levels, and physiological aging.
Socks provided to the amputee are a readily
available solution for patients to accommodate
these daily volumetric changes. Modications to
the socket might be necessary by heating and
changing the shape, or addition/subtraction of
padding. If a patient’s limb has changed signicantly, a socket replacement would be required to
ensure optimal t and function.
Patients’ needs continually evolve. Functions
change over time. It is imperative for the clinical
team to have ongoing dialogue to ensure patient
needs are met. One must not overlook the importance of including the patient within this dialogue. According to Valizadeh, there is a
signicant difference in what the clinical team
deems essential when compared to what the
patient perceives to be essential [22]. Continued
discussions can ensure patient needs are met in
conjunction with professional input, rather than
based entirely on clinical assumptions. Surveys
and outcome measures provide an additional
avenue to enhance patient communication and
success. The self-reported measure of the
Prosthetic Limb Users Survey of Mobility
(PLUS-M) provides a means for the patient to
provide insight in order to assist with their clinical care [44].
Summary
A collaborative team provides patients with
diverse clinical opinions in an effort to optimize
patient function. Gait salvage is the goal in an
effort to ultimately reduce mortality rates. This
can be accomplished through limb salvage or
amputation. Preventative measures are prioritized to save the at-risk, dysvascular limb.
Orthotic intervention provides pressure distribution to prevent or treat ulcerative or contracted
limbs to allow for healing. When healing is not
likely, or would yield low function, amputation
provides another means to improve gait. Peer
support, ACC, and prosthetic consultations are
resources available to the patient that can help
overcome physical and mental obstacles associated with amputation. Post-operative care prepares the patient for prosthetic intervention and
ambulation. A preparatory prosthesis allows for
early ambulation along with setting realistic
goals and expectations, assisting in designing the
25 Prosthetics, Orthotics, andAmputation Rehabilitation
357
rst denitive prosthesis, intended for long-term
use. Ongoing collaboration with the prosthetist,
physical therapist, and limb salvage team provides each patient with a complete clinical plan
designed to meet individual needs and optimize
outcomes.
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Surgical Ooading, Tendon
Balancing, andProphylactic
Surgery inDiabetic Limb Salvage
JohnS.Steinberg, PaulJ.Carroll, JaysonN.Atves,
andJohnD.Miller
26
Introduction
Surgical indications and techniques for limb salvage in the complex patient population are a constantly evolving eld of medicine and surgery.
Commonly, patients present with a biomechanically induced ulceration of the foot or ankle,
peripheral neuropathy, and some degree of concomitant relative tissue ischemia. Beaulieu etal.
reported the majority of these patients often have
multiple conditions and comorbidities which
challenge limb salvage efforts [1]. Further,
Hobizal and Wukich noted several host factors
including medical comorbidities, nutritional status, glycemic control, nonadherence to medical
regimens, and socioeconomic status play a central role in patient outcomes [2].
J. S. Steinberg
Department of Plastic Surgery, Georgetown
University School of Medicine and MedStar
Georgetown University Hospital,
Washington, DC, USA
e-mail: John.Steinberg@medstar.net
P. J. Carroll
Department of Plastic and Reconstructive Surgery,
MedStar Franklin Square Hospital,
Baltimore, MD, USA
e-mail: Paul.J.Carroll@medstar.net
J. N. Atves (*) · J. D. Miller
Department of Plastic and Reconstructive Surgery,
MedStar Georgetown University Hospital,
Washington, DC, USA
e-mail: Jayson.Atves@Medstar.net
Following improvements in surgical technique
and perioperative management, indications for
surgery in the patients with diabetes have
expanded. In 2003 Armstrong and Frykberg
revised diabetic foot surgery classication into
categories of indication based on risk [3] as seen
in Table26.1. Importantly, they established the
concept of elective and prophylactic surgeries in
the diabetic population shifting a paradigm of
surgical intervention from “last-resort” to “early
prevention.” Using this system methods for surgical ofoading range from prophylactic tendon
lengthening and transfers to curative procedures
with adjunctive surgical ofoading techniques. In
this chapter we review the guiding tenets for surgically based ofoading pedal ulcerations utilizing ostectomies, osteotomies, tendon balancing,
and other prophylactic surgery in the complex
patient population.
In the complex and comorbid populations,
especially in those patients with peripheral neuropathy, the formation and complication of
deformity can create a perilous situation which
precipitates wound formation, progression, and
stagnation. As with deformity at any level of the
lower extremity, this situation can not only
impede one’s ability to ambulate safely and
effectively but also has major implications for
quality of life. This lends to the major role and
need for consideration of ground reactive forces
throughout the lower extremity and the body’s
susceptibility to the formation of multi-level and
© Springer Nature Switzerland AG 2023
C. E. Attinger, J. S. Steinberg (eds.), Functional Limb Salvage,
https://doi.org/10.1007/978-3-031-27725-2_26
359
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J. S. Steinberg et al.
multi-tissue deformity, especially in the face of
peripheral neuropathy. Although the full extent
of lower extremity biomechanics lies well outside the scope of this discussion, ultimately, gait
biomechanics in the complex wound patient are
an especially important consideration due to the
lower extremity’s relationship with the weightbearing surface, its interaction with ground reactive forces, and perhaps most importantly in a
patient’s ambulatory efforts and demands.
Inherently, the extremity’s contact with the
ground in an ambulatory manner will repetitively undergo extreme multiplanar forces which
Table 26.1 Risk-based classes of diabetic foot surgery.
Adapted from: Armstrong, D.G. and Frykberg, R.G.
(2003), Classifying diabetic foot surgery: toward a rational denition. Diabetic Medicine, 20: 329–331 [3]
Potential risk
Diabetic foot
surgery class Description
Class I:
elective
Class II:
prophylactic
Class III:
curative
Class IV:
emergent
Procedure performed to
alleviate pain or
limitation of motion in a
person without loss of
protective sensation
Procedure performed to
reduce risk of ulceration
or re-ulceration in
person with loss of
protective sensation but
without open wound
Procedure performed to
assist in healing open
wound
Procedure performed to
limit progression of
acute infection
for high-level
amputation
Very low
Low
Moderate
High
may precipitate excessive force distribution
resulting in and contributing to the formation of
an assortment of pathologies which may also
blunt the remaining tissues ability to heal or
cause the formation of new areas of excessive
force. This is nowhere more apparent than in the
plantar aspect of the foot; however, anatomic
areas surrounding joints with signicant excursion like the ankle, midtarsal, tarsometatarsal,
metatarsophalangeal, and interphalangeal joints
are especially susceptible. This process is magnied in those patients where underlying deformity exists in the presence of peripheral
neuropathy, where protective and corrective
responses to ground reactive forces are blunted
or grossly absent (Table26.2).
Deformity of the foot and/or ankle may present in a variety of ways which may perpetuate
wound formation and its correction may preclude
the ultimate healing of a wound through undesirable and ultimately destructive force distribution
within the extremity or the formation of altered
mechanics which can irreparably alter gait. A
deformity of the foot and/or ankle is truly of
functional signicance when the tissues do not
permit sufcient mobility for the alignment and
motions required during the normal gait cycle.
Abnormal bone or joint alignment, ankylosis,
and/or instability often occur in the foot and/or
ankle but the onus of recognition of the exact
anatomic level(s), plane(s), severity of deformity
and especially the formulation of appropriate
intervention(s) and/or consultations is ultimately
placed upon the treating surgeon and team. The
Table 26.2 Excessive plantar pressures and causative ulcer factors
Intrinsic factors Extrinsic factors Behavioral factors Iatrogenic factors
• Limited joint mobility • Non-adapted footwear
(too tight, prominent
seams)
• Congenital, post-traumatic, other
severe foot deformities (Charcot)
• Foreign body (pebbles,
nails, etc.)
• Barefoot/
unprotected
walking
• Lack of daily foot
surveillance
• Impossibility of
foot care
• Poor hygiene • Escalating amputations
• Unstable biomechanics
• Poorly performed
debridement/amputation
• Resection of 1 or more
metatarsal heads
26 Surgical Ooading, Tendon Balancing, andProphylactic Surgery inDiabetic Limb Salvage
361
primary goal of foot and/or ankle reconstruction,
whether prophylactic or therapeutic, should be to
provide a structurally well-aligned and stable
foot and ankle complex. Treatments should seek
to achieve a plantigrade foot which provides
dynamic alignment and stability during stance
phase, clearance during swing phase, adequate
step length and provides energy conservation
throughout.
Goals ofSurgical Intervention
Fundamental goals of limb salvage surgery
include obtaining an infection-free, plantigrade,
and stable extremity ideally maximizing ambulatory function within the patient’s physical and
medical capacity [4]. Also core to these tenets is
the recognition and removal of high force areas
where and when possible. Areas of callous formation with or without associated overlying erythema may indicate areas of osseous deformity
predisposing to ulceration. Any foot or ankle
deformity, be it hallux limitus, hammertoes,
osteoarthritis, equinus, bony prominences, and/or
Charcot neuroarthropathy, may play a causal role
in force-induced ulcer development, stagnation,
and chronicity. Raspovic etal. demonstrated that
biomechanically induced ulcerations will inevitably lead to re-ulceration, increased amputation
risk, and a decrease in quality of life unless corrected [5]; therefore, recognition of their presence
and understanding of their potential progression
warrant preemptive and proactive mentality in
treatment.
Soft tissue changes may also contribute to
lower extremity ulceration and should always be
assessed. Plantarly prominent metatarsal heads
have been attributed to developed weakness of
the intrinsic pedal musculature, exacerbating
plantarexion toe deformities in the neuropathic
foot. Adipose cushioning under the metatarsal
heads is embedded within the exor tendons and
is believed to migrate distally with progressive
hammering of the lesser digits, further reducing
plantar cushioning of the metatarsal heads [6].
Additional nonenzymatic glycation of soft tissues resulting from long standing diabetes mellitus may also lead to thickening and reduced
tissue exibility of skin, tendon, ligaments, and
joint capsules [7]. Although innocuous appearing, digital contractures in higher risk patients
quickly progress to a preulcerative or ulcerative
state. Therefore, early detection and minimization or removal of these excessive forces is critical in prevention or maintaining remission from
ulceration.
Imaging andDiagnostics Studies
Radiographs
Plain lm radiographs in multiple views are
imperative for evaluating wound etiology particularly if the wound is located on a weight-bearing
surface, as bony irritation on the foot or ankle can
potentiate wound formation or support chronicity. Weight-bearing plain lm radiography may
conrm or better dene osseous relationships and
may display preliminary signs of underlying vascular disease such as calcications. Transverse,
frontal, and sagittal plane joint relationships may
be evaluated and joint integrity can be investigated prior to clinical assessment. These parameters are essential when planning musculoskeletal
balancing procedures.
Advanced Imaging
Advanced imaging techniques such as magnetic
resonance imaging (MRI), computed tomography (CT), or radiolabeled scintigraphy/nuclear
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J. S. Steinberg et al.
scans may be appropriate for some patients in
whom initial evaluations suggest osteomyelitis
(OM). MRI may be useful to image the deeper
layers of the foot and ankle. CT may be used to
visualize changes in the cortical bone due to
infection or for anatomical contour, position,
and/or alignment. However thorough clinical
evaluation and weight-bearing plain lm radiographs are often all that is needed for
assessment.
First Digit andMetatarsophalangeal
Joint
First Metatarsophalangeal Joint
Arthroplasty
Limitations in rst metatarsophalangeal joint
(MPJ) mobility are a common forefoot occurrence contributing to plantar hallux ulceration.
While pressure reduction is usually attempted
with external shoe modications, this alone will
not correct underlying osseous deformity and
may result in an ulcer development despite best
practices [8]. In 1886 Reidel described resection
of the base of the proximal phalanx and exostectomy of the head of the rst metatarsal as an
alternative to unsatisfactory outcomes of rst
metatarsal head resection. This was later popularized by U.S. Army Captain William Keller in
1904, and more recently the efcacy of a Kellertype rst MPJ arthroplasty procedure in diabetic
patients with plantar rst MPJ ulceration secondary to arthritic joint immobility has been well
established [9] (Fig.26.1). Patients who received
surgical resection of the base of the proximal
phalanx were noted to heal their plantar ulceration faster than the nonsurgical group without
signicant increase in complications and without
prolonged recovery time [10].
Procedure
Patient is placed in the supine position. After
administration of preferred anesthesia and intravenous antibiotics an Esmarch is applied and the
ankle tourniquet inated. A dorsomedial skin,
deep, and capsular incision is made over the rst
metatarsophalangeal joint, protecting the dorsal
medial cutaneous nerve and extensor hallucis
longus tendon. If present, osteophytes are
resected from the rst metatarsal head surrounding the joint. Resection arthroplasty of the base
of the proximal phalanx with oscillating sagittal
saw typically involves a generous resection of the
proximal phalanx, potentially up to one-third of
the phalanx. Aggressive resection can include
insertion of the exor hallucis brevis, which may
lead to toe shortening with transfer metatarsalgia
and weakness in toe push-off.
Various modications of soft tissue interpositional arthroplasty have been reported including
autografts (extensor hallucis longus, extensor
hallucis brevis, and extensor digitorum longus),
allografts, and acellular tissue matrices.
Commonly the remaining capsule is then transversely interposed into the joint and sutured to
the lateral capsule with absorbable suture.
Typically the joint is axially xated with 0.062mm Kirschner wire from ~5 degrees of valgus
and ~10 to 15 degrees of extension. The foot is
dressed in standard postoperative dressing and
postop shoe. Sutures and Kirschner wire are
removed in the clinic at 3weeks, at which time
the patient was allowed to bear full weight in a
hard-soled shoe and begin range of motion.
Regular shoes and activities were gradually
advanced at that time.
26 Surgical Ooading, Tendon Balancing, andProphylactic Surgery inDiabetic Limb Salvage
ab
cd
363
Fig. 26.1 Clinical images (a, c) and radiographic images
(b, d) multiple views—preoperative (a, b) and postoperative (c, d) status post-Keller style arthroplasty of the rst
metatarsophalangeal joint. This specic patient experienced increased postoperative mobilization of the dorsi-
exion motion of the rst metatarsophalangeal joint and
decreased ground reaction force to the hallux with subsequent healing of the chronic recalcitrant plantar hallux
wound
364
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J. S. Steinberg et al.
Lesser Digits
andMetatarsophalangeal Joints
Lesser digital deformities such as hammer, claw,
and mallet toes are frequent and known to
increase pressure associated with neuropathic
ulceration [11]. Lesser digit ulcerations are often
the result of structural deformity and therefore
are associated with high rates of recurrence [12].
Rigid digital contractures may cause preulcerative or ulcerative lesions to the dorsal aspect of
contracted joints due to rubbing in shoe gear and
also to distal digits. Contractures that are manually reducible may be corrected with soft tissue
release alone; however, if the deformity is rigidly
contracted and nonreducible it typically requires
joint arthroplasty for correction.
Percutaneous Flexor Tenotomy
If the long exor tendons overpower the intrinsic
musculature, a exion deformity of the DIPJ
level is likely to occur. As a result, the distal tip of
the digit will become plantarexed with increasing pathologic pressures resulting in hyperkeratotic buildup and eventually ulceration in the
neuropathic patient [12]. Flexor tenotomy can be
performed for prevention of diabetic foot ulcers,
in exible lesser digits. Based on 6 published retrospective studies regarding exor tenotomies for
diabetic ulceration a total of 264 tenotomy procedures yielded a mean healing rate of 97% at a
duration of 4 weeks [13]. While the lasting preventative effects of exor tenotomy are not yet
well described, current results demonstrate that
exor tenotomies are a simple, effective, and
low-risk intervention for reducing non-rigid hammer and claw toes with a high healing percentage
and a short mean time to heal. These procedures
can also be done in an ofce setting with limited
equipment costs and time constraints.
Procedure
Following completion of anesthesia per physician preference. The exor digitorum longus of
the selected digit is placed under tension (“bowstringing”) by positioning the ankle joint in dor-
siexion, while at the same time positioning the
affected toe in hyperextension. A stab-wound
incision (around 3mm) is made at the middle of
the proximal phalanx by either blade or 18-gauge
needle (author’s preference), and the tendon is
transected in a transverse swiping motion. The
long extensor tendon should now hold the toe
straight. All stab wounds should be irrigated and
may or may not require suture. Typically a pressure bandage is applied for the rst week. The
foot remains ofoaded for 24h, after which the
patient can bear weight again. The patient is
examined at 1-week and subsequently followed up at regular intervals.
Lesser Digital Arthroplasty
If contracture unrelieved by percutaneous exor
tenotomy or the deformity is precluded from soft
tissue reduction by nature of being a rigid deformity, digital resection arthroplasty may allow for
contracture reduction to facilitate wound healing
and/or reduce the risk of wound recurrence [14].
Resection at the proximal interphalangeal joint
permits shortening which allows for correction of
deformity and relaxation of contracted soft tissues (Fig.26.2). If reduction is still not possible
following adequate resection, extensor tendon
lengthenings or dorsal MPJ capsulotomies may
be performed to augment reduction.
Procedure
Digital or ankle local anesthesia blocks are
administered as needed. The affected proximal
interphalangeal joint is surgically exposed by
either dorsal longitudinal incision or transversely with the skin tension lines at the level of
the joint. Dissection is carried out to expose the
distal condyles of the proximal phalanx and a
transverse supracondylar resection is made with
bone-cutter or sagittal saw as desired. A 0.045″
Kirschner wire is then introduced at the proximal interphalangeal joint centrally and exited
distally. The toe may then be digitally manipulated and the wire passed proximally to stabilize
the digit in the corrected position. The wire may
then be bent external to the digit to prevent
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