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Featured
Lecture
Amputations - Forefoot and Rearfoot
by Michael Cohen, DPM
Chief of Podiatry and Director of Residency
Education
Veterans Affairs Medical Center in Miami Florida
Michael Cohen has been around a lot longer than we have all been lead to
believe. In his lecture on forefoot Amputations, he describes the scene during
Civil War, when the procedure was done without anesthesia, using wood handled,
non-sterile instruments. Photographs within the lecture depict the Dr. Cohen of
yesteryear, bravely addressing the needs of the battered soldiers in a desperate
time in America’s History. Notice the resemblance ?
Times have changed quite dramatically, yet amputation surgery still represents a
circumstance in which the foot and ankle specialist is forced to deal with life
and death issues, just like the battlefield surgeons of old. In fact, 50%
of the population of patients who undergo non-traumatic related amputations die
36 months after surgery. 50% of amputation patients undergo amputation surgery
on the contralateral limb with 2 years. Fortunately, great strides have been
made in the specialty areas of vascular surgery and invasive cardiology. Bypass
procedures into the foot, into one of the trifurcation vessels, angioplasty and
stenting provide improvement in the ischemia and assist in wound healing.
Unfortunately, these come with a “ticking time clock complete with alarm”.
In
his 2 lectures on modern amputation techniques, Dr. Cohen discusses factors that
are critical for healing of wounds and amputation sites, such as serum albumin,
total lymphocyte count and ABI’s/TCPO2. Of course, a thorough vascular
assessment is essential. Is the skin shiny? What about hair growth? Do ischemic
lesions exist? Dr. Cohen reviews invasive and non-invasive evaluations.
Case studies that discuss the importance of adequate debridement and proper
antimicrobial therapy, both intra op and post operatively are presented. An
understanding of how infections track along tendon sheaths and the anatomical
compartments of the foot is vital.
Despite our best efforts, ray resections have a failure rate of 45% - 65%.
Transmetatarsal amputations seem to have a higher rate of success (95%). It is
imperative that all specialists work as a team and the patient is a willing
participant. In addition, the involvement of a good prosthetist greatly enhances
the likelihood of success.
Settle back, pop open a soda and listen to parts I and II of Michael
Cohen's definitive lecture on Forefoot and rearfoot amputations.
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