Amputations at the middle level of the foot. A retrospective and prospective review.

Recent trends in amputation surgery favor amputation at the most distal level to preserve the patient's ability to walk. This paper reports the results of sixty-four amputations performed at the level of the middle of the foot in fifty-eight patients. All were performed in patients with peripheral vascular disease who had a diagnosis of either gangrene or resistant, nonhealing ulcers. Forty-three patients (74 per cent) had diabetes. Nutritional evaluation of the patient was used to improve the potential for healing. In the initial forty-six patients, a retrospective review of the serum albumin level, the blood total-lymphocyte count, and the Doppler ischemic index was performed. A prospective study was performed in the final twelve patients, in whom a minimum level in each of these three factors was required before the distal amputation was done. The healing rate for all sixty-four amputations was 81 per cent. When all three factors were above the minimum level, the healing rate was increased to 92.2 per cent. When one or two of the factors was below the minimum level, the rate of healing decreased to 38.5 per cent. Aggressive distal amputation can be performed with a high rate of success when the factors influencing the decision on the amputation level include non-invasive vascular testing and nutritional evaluation.