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Foot & Ankle International http://fai.sagepub.
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The Dysvascular Foot: A System for Diagnosis and Treatment

F. William Wagner, Jr.
Foot Ankle Int 1981 2: 64
DOI: 10.1177/107110078100200202
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FOOT8 ANKLE
Copyright 0 1981 by the American Orthopaedic Foot Society. Inc
The Dysvascular Foot: A System for Diagnosis and Treatment
F. William Wagner, Jr., M.D. *

Whittier. California
Orthopaedic treatment of the dysvascular foot and 2. Chronic chilblains (pernio)

ankle can be frustrating, disheartening, difficult, im- 3. Ergot poisoning
possible, and yet satisfying and rewarding. Amputa- 4. Catacholamine oversecretion
tion, that most dreaded of all clinical procedures, is 5. Livedo reticularis
most often caused by circulatory disturbances. Dys- 6. Raynaud's disease and syndrome
vascular patients make up 80% of the thousands of 7 . Sympathetic reflex dystrophy
patients who undergo lower extremity amputation 8. Vasoconstricting drugs
each year.3. 46 Of this group, 50 to 70% are now 6. Organic
diabetic.15, 36, 5 3 . 60 1. Diabetes mellitus
The foot mirrors all aspects of circulatory dysfunc- 2. Collagen diseases
t i ~ n Arterial,
. ~ ~ venous, and lymphatic disturbances a. Dermatomyositis
produce signs and symptoms that will suggest the b. Felty's syndrome
diagnostic procedures to be used. Clinical findings c. Nodular vasculitis
and test results will then indicate the treatment pro- d. Periarteritis nodosa
gram to be followed. e. Rheumatoid arthritis
This review cannot be a treatise on all vascular f. Lupus erythematosus
disorders. A partial outline will give some indication of g. Scleroderma
vascular disorders of the lower limb that affect the C. Hypertensive ischemia
foot. D. Gout
I. Proximal Arterial Occlusive Disease E. Arteritis, hypersensitivity disseminated
A. Atherosclerosis F. Arteritis, infectious
B. Buerger's disease (thromboangiitis obliter- G. Thrombocytopenic purpura
ans) H. Psoriasis
C. Arterial embolism I. Osteoarthritis
D. Arterial injury 111. Venous Disease
E. Arterial compression (tumor, local inflam- A. Superficial thrombophlebitis
mation, tourniquet, cast, ligature, compart- 1. Benign, migrans
ment syndrome) B. Deep thrombophlebitis
F. Aneurysm, dissecting, ruptured, throm- 1. Phlebothrombosis
bosed 2. Nonsuppurative popliteal and iliofe-
G. Abdominal coarctation moral thrombophlebitis
H. Retroperitoneal fibrosis 3. Suppurative iliofemoral thrombophle-
I . Hyperplasia, fibromuscular, intimal bitis
J. Congenital dysplasia C. Primary varicosities
II. Distal Arterial Occlusive Disease IV. Occlusive Lymphatic Disorders
A. Vasospastic A. Congenital lymphedema
1. Acrocyanosis B. Congenital familial lymphedema (Milroy's
disease).
C. Lymphedema precox
D. Malignant obstruction of regional lymph
' Clinical Professor of Orthopaedic Surgery, University of South- nodes
ern California School of Medicine; Chief Consultant, Orthodiabetes
Service, Rancho Los Arnigos Hospital; and Chief of Foot Service,
E. Inflammatory lymphedema
Los Angeles County, University of Southern California Medical F. Lymphangiosarcoma
Center. G. Fibroedema (elephantiasis)
64
Foot & Ankle/Vol. 2, No. 2 THE DYSVASCULAR FOOT 65
V. Exposure to cold mines the treatment program into which the patient is
A. Frostbite started.
B. Chilblains, acute-chronic
C. Trench foot GRADING OF FOOT LESIONS
D. Immersion foot
Bernard Meggitt, F.R.C.S., now of Cambridge, Eng-
VI. Post-traumatic Vascular Disorders
land, aided in the development of the grading system
A. Major causalgia
while he was a fellow at Rancho Los Amigos Hospital.
B. Post-traumatic vasomotor disorders
The system was developed through observing pro-
1. Sudeck's atrophy
gression of diabetic foot lesions from callus to ulcer,
2. Painful osteoporosis
to abscess, to gangrene, and finally to surgical abla-
3. Reflex sympathetic dystrophy
tion. It has been found that lesion grading and flow
The major treatment of most of these problems is
charts or algorithms will apply in virtually every foot
performed by the internist or the family practitioner
problem associated with vascular and neurological
with some grounding and interest in the problems.
conditions. The chart of the natural history of foot
Orthopaedic treatment is indicated for reconstructive
breakdown depicts a return arrow to Grade Zero from
procedures in the foot and ankle and for ablative
all of the grades except Five (Fig. 1). This indicates
procedures. The vascular surgeon is consulted when
that any grade except Five may be converted back to
revascularization or other direct vascular treatment is
a Grade Zero foot which has no open lesions. There
indicated.
still may be bony deformity or only a partial foot
In the past two decades, there has been a marked
remaining. Although the Syme's amputation has been
increase in interest toward extension of longevity and
considered a long below the knee amputation, we feel
improvement of the quality of this extended life. At
that it is technically a partial foot amputation. The
one time, 80% of all lower extremity amputations were
remaining heel pad is still a portion of the foot and the
performed above the knee.33 46 Now, with improved
sensory and feedback mechanisms are still those of
diagnostic and treatment techniques, 80% of these
the heel.
amputations are performed below the knee.7 At some
Foot lesions are divided into six grades.66,68 The
centers, more and more procedures are performed at
determination of grade is based on the depth of the
and below the knee (Table 1 ) . 2 5 . 2 7 . 48 With increased
skin lesion and the presence or absence of infection
longevity, the incidence of degenerative arterial dis-
and gangrene.
ease is increasing. Unfortunately, prophylactic treat-
ment of atherosclerosis is of little or no immediate help Grade Zero
when gangrene or an infected ulcer is present. Ces-
There are no open lesions in the skin, although
sation of smoking, low cholesterol diets. intake of
there may be evidence of healed lesions (Fig. 2).
unsaturated fatty acids, and regular exercise program
There may be bony deformity, such as clawtoes, de-
can slow the progression of new lesions. However,
pressed metatarsal heads, Charcot joint changes, and
this is most difficult in the 40- to 55-year age group
partial amputations such as toe (Fig. 31,toe and ray,
when progression of the primary disease is most
transmetatarsal, Lisfranc and Chopart, calcanecto-
marked. Coronary, cerebral, or renal artery disease
mies, partial or complete, and Syme's amputations.
most commonly lead to the patient's demise.
Against this background, the treating physician
must weigh the pros and cons of local medical and DYSVASCULAR FOOT BREAKDOWN-
surgical treatment, revascularization procedures, and NATURAL HISTORY
mAr I I I I
amputation. At Rancho Los Amigos Hospital, a service r I I I 1
GRADE I GRADE 2 GRADE 3 GRADE 4 GRACE 5

)as been established for the care of dysvascular
voblems of the lower extremities. Most of the patients
I
O GANGRENE
7ave diabetes mellitus with or without atherosclerosis. No OPEN SUPERFICIAL DEEP ABSCESS GANGRENE ENTIRE
LESION ULCER ULCER OSTElTlS FOREFOOT FOOT
I----
-IAA__J_,I
Ihe nondiabetics have mainly major arterial lesions.
home have vasculitis associated with rheumatoid ar-
thritis and other collagen diseases. A few have ulcer-
ation associated with venous incompetency and pot- I
3hlebitic changes.
The symptoms or complaints that most often bring I '
ne patient to the physician are claudication, rest pain,

I
I
I' il I 1 .i
or an unhealing ulcer. To match the patients with c u L
eatment programs, a system in which the foot is Fig. 1. Grading of foot lesions The arrow indicates that all grades
raded has been developed. This grade then deter- except Five can be converted to a Grade Zero foot
66 WAGNER Foot & Ankle/Vol. 2 . No. 2
Grade One
There is a superficial ulcer without penetration to

deeper layers. Again, bony deformity may be present
and a bony prominence frequently underlies the ulcer
(Figs. 4 and 5).
Grade Two
The ulcer is deeper and reaches tendon, bone, or
joint capsule. Bony prominence of some degree usu-
ally is present (Fig. 6).
Grade Three
Deeper tissues are involved and there is abscess,

osteomyelitis, or tendinitis, usually with extension
along the midfoot compartments of tendon sheaths.
Such external signs of infection as heat, redness, and
swelling may be less than would have been expected
when the degree of infection is exposed at surgery
(Fig. 7).
Fig. 2. Grade Zero foot. Note healed ulcer over third proximal
interphalangeal joint. Note claw toes and chronic nail changes.
There are no oDen lesions.
Fig. 4. Grade One lesion after first walking-cast treatment (final

Fig. 3. Grade Zero foot. Healed amputation of right great toe. result in Fig. 2).
Foot & Ankle/Vol. 2 , No. 2 THE DYSVASCULAR FOOT 67
An algorithm is an ordered sequence of mathemat-

ical steps that always produces the correct answer to
a problem. A flow chart is a graphic representation of
the major steps of work that are in progress. Symbols
may represent actions, documents, machines, or sim-
ilar entities. Emphasis is on what is done rather than
how it is done. Combining these produces a step-by-
step sequence that should produce a solution to the
problem presented by a particular dysvascular foot.
The elements of the algorithm are the oval, the rectan-
gle, the diamond, and the arrow denoting direction of
flow.
The oval is a starting or finishing condition or posi-
tion. The arrows show progression from condition of
entry into the program through diagnostic and treat-
ment entities to the final condition (Fig. 9).
The rectangle represents an action or actions to be
taken, such as diagnostic tests, surgical procedures,
Fig. 5. Grade One lesion over heel cord. This was from a pene-
trating injury. Treatment with walking cast with complete healing.
Grade Four
There is gangrene of some portion of the toe, toes,

and/or forefoot. The gangrene may be wet or dry,
infected or noninfected, but in general, surgical abla-
tion of a portion of the toe or foot is indicated (Fig. 8).
Grade Five
Gangrene involves the whole foot or enough of the

foot that no local procedures are possible and ampu-
tation must be carried out, at least, at the below the
knee level.
Each grade of foot lesion obviously will require
different treatment at different stages of development.
Treatment programs based on the foot grade have
been developed. To aid in decision making, algorithms
or flow charts have been constructed for each
grade."" 68
ALGORITHM OR FLOW CHART
Algorithm and flow chart are terms borrowed from

mathematics and industry. They are becoming in-
creasingly useful in medical problems, as consider-
Fig. 6. Grade Two lesion after several weeks of walking-cast
able information can be presented in a minimum of
treatment. The patient previously had required amputation of the
space. The terms are not found in the medical diction- fifth toe. This lesion began under the fourth metatarsal head. Note
aries as yet, but may be found in biomedical engi- granulation tissue now covering deeper tissues. Wound filled in
neering reference works. completely with walking-cast treatment.
68 WAGNER Foot & Ankle/Vol. 2 , No. 2
Fig. 7. A Grade Three lesion with deep abscess. The patient has
a short transmetatarsal amputation. The special shoe and insert Fig. 8 . Gangrene of all toes and metatarsal head area. Infection
prescribed had not been worn. This patient required a Syme's extends to rnidfoot. Blood supply is sufficient for a below the knee
amputation when the ulcer was explored, and no local procedure amputation.
was possible.
counseling etc. The arrow then directs progression to

the diamond or to the oval (Fig. 10). SKIN INTACT PROSTHESIS
The diamond represents a question, a test result, or
a condition presented as a question that can be an-
Fig. 9. The oval represents a starting or finishing condition. l h e
swered "yes" or "no." The next step is determined arrow directs progress to the next procedure.
by the yes or no answer (Fig. 11).
An explanation of each of the steps in the six
algorithms and presentation of representative cases
will aid in their use. It should be possible to treat
virtually any problem foot case with this system.
___I
T- ---'
TEAM APPROACH
It has been found at many centers that a team Fig. 10. The rectangle represents an action to be taken, such as
a test or a surgical procedure.
approach provides consistently superior result^.^^^
At times, a surgical procedure may be the major
treatment indicated. However, surgery is only a link in different people and specialties involved in solving the
the long chain of related steps leading to useful func- immediate medical and surgical problems of the dys-
tion. Surgical correction of the diasbility or disabling vascular foot and in returning the patient to an active
condition is not, in itself, the final solution of the and useful life. The team varies in size and composi-
problems of the handicapped person. There are many tion, depending upon the type of hospital and the
indicated level, and for patients with claudication and

rest pain.
Radiologist
Diagnostic X-rays aid in the detection of osteomye-

Fig. 11. The diamond represents a question that can be answered litis, Charcot bone and joint changes, and gas and
'yes" or "no". The arrow directs the next step based on the
other soft tissue changes. The radiologist has become
answer.
expert in the performance of invasive vascular tests.
Angiograms now provide a "road map" of the vascular
departments available. Some outside members may tree which aids in the selection of surgical corrective
be called in as consultants when a particular problem procedures.
arises in their field of expertise.
At Rancho Los Amigos Hospital, the co-leaders are Plastic Surgeon
an internist and a surgeon. Since the greatest number
of patients are diabetics, the internist is a diabetolo- On occasion an ulcerated area may require flap
gist. Because most of the surgical procedures are on coverage rather than skin grafting. The techniques of
the extremities, the surgeon is an orthopaedist. flap rotation: crossleg, transverse, and microvascular-
free pedicle transfers, are highly specialized and re-
Team Leader-Orthopaedic Surgeon quire special training and continued practice.
The orthopaedist should have an interest in caring
Nuclear Medicine Specialist
for the foot and should be skilled in amputation sur-
gery. He is assisted by an orthopaedic fellow, ortho- Injection or transcutaneous absorption of radioac-
paedic resident, and occasionally an intern on elective tive substances can provide information through lo-
rotation. Medical students also may attend on elective calized concentrations and timing of dissipation of the
rotations. radioactive 44 Function of organs and 10-
calization of tumors and infectious processes can be

Co-Leader-Internist, Diabetologist, Endocrinologist assessed through these studies.
The internist is assisted by fellows, residents, in-
terns, and occasionally, medical students. Diagnostic Nursing
procedures are obtained and treatment is rendered as Ward Nurse. Multiple problems of diabetic control,
indicated. The care of diabetic^,^. 5 0 hypertensives, generalized and local infections, decreased cardiac
and other cardiovascular patients is monitored function, decreased kidney function, and similar prob-
closely, especially in the pre- and postoperative lems can add to general nursing duties. Daily wound
stages. Antibiotic coverage is coordinated between care is of major importance in the patients who may
the medical and surgical staffs unless the patient does heal without surgical procedures. The Ward Nurse
not respond in the expected manner. has been the staunchest ally of the medical and sur-
gical staff.
Infectious Disease Specialist
Nurse Anesthetist. Nurse anesthetists supervised
Care of the infected patient, on occasion, falls out- by anesthesiologists provide the major number of
side the expertise of the medical and surgical staffs. inhalation anesthetics. Regional intravenous anesthe-
Development of resistant strains of bacteria and infec- sia, regional nerve block, local anesthesia, and spinal
tion with multiple organisms may require the additional anesthesia are performed by the surgeon or the anes-
help of the infectious disease specialist. thesiologist.
lntensive Care Nursing. Immediate postoperative
Vascular Surgeon
complications have been markedly reduced with spe-
Surgical revascularization of the dysvascular lower cialized nursing care for these difficult cases in the
limb has attained a place of major importance.". * * , 3*. first 24 hr postoperatively.
39 59
With restoration of some degree of blood flow, Nurse Practitioner-Liaison Nurse. A group of
local lesions may heal, local foot surgery may suc- nurses has been given special training in diabetic and
ceed, the amputation levels can be kept below the foot care. The nurses have been provided with teach-
knee in the highest percentage of cases. Vascular ing aids so that the patients may be instructed about
consultation is obtained when the ischemic index is care of diabetes mellitus and about their own foot
below that necessary for local healing, when the index care. These nurses attend both diabetic and foot
is below that for surgical healing at the clinically clinics and help in coordinating medical and surgical
treatment. In addition, house calls may be made to Pedorthist

assess home and family conditions.
Supplying available protective shoewear to the pri-
vate patient can be a problem in cities without ortho-
Medical Social Worker
paedic shoe stores. The Prescription Footwear Asso-
Most patients with dysvascular problems of the feet ciation (PFA) now certifies pedorthists, aids in their
are older; many are past working age; and many are precertification training, and will aid in their continuing
on some type of pension or public assistance program. medical education. Proper shoe selection with special
The social worker acts as an interface with the family, attention to pressure relief, tips on donning shoes,
government agencies, and courts, and aids in financial and warnings on breaking in new shoes are all part of
planning. Special help is provided with housing follow- the pedorthist care program. He is able to fabricate
ing hospitalization. all shoe modifications as well as custom-made shoes.
Psychologist Occupational Therapist
One of the devastating thoughts that strikes many Upper extremity strengthening and dexterity are
of these patients on their entry to the hospital is that under the supervision of the occupational therapist.
a major portion of a limb will be lost. Being on a ward Activities of daily living are emphasized to prepare the
with similar patients helps in their understanding of patient for release from the protective environment of
the problem. Many an experienced amputee has found the hospital. Many of our patients have had burns
himself as a role model for a new patient. The psy- from hot liquids that spilled or were tipped from a
chologist is able to give reassurance pre- and post- stove. Learning safety before returning to the kitchen
operatively and will arrange meetings with helpful is of highest priority. Also, being able to shop wisely
patients. Sex counseling can, also, be of major help. is closely monitored.
If problems become too deep-seated, psychiatric help
Cast Technician
may be needed.
Walking casts, protective molded splints, casts fol-
Vascular Technician lowing surgery, edema-control casts, and other vari-
Noninvasive tests have aided markedly in assessing ations of the plaster dressing are an important part of
the vascular status of the lower extremities. Doppler the treatment program of the dysvascular foot and
ultrasound, thermography, transcutaneous oxygen ankle. Because of the large volume of work the med-
analysis, and similar tests are performed. A system ical staff members are unable to apply most of the
for use of Doppler laser is being developed. casts. Technicians have been trained to apply these
casts and to aid in the training of the resident staff in
Prosthetist the principles of cast management.
Ordering a prosthesis is dependent on input from Physical Therapist

the whole team. In some patients, the cardiovascular
Preoperative and postoperative evaluation of phys-
status is so marginal that the extra energy output
ical strength and dexterity are provided by the physi-
necessary to use a prosthesis is not available. The
cal therapist. Instruction is given in the use of shoe
prosthesis ordered may range from a cosmetic "pants
modifications, braces, and prostheses. Home calls are
filler" to a sophisticated limb with hydraulic controls,
made to check stairs, halls, toilets, and ramps. Orders
safety knee mechanisms, torsional stress relievers,
are written for ramps, bars, and assistive devices as
and five-way ankle joints. Fabrication of the prosthesis
necessary. Close coordination is maintained with the
is followed by fitting and adjustment. The prosthetist
orthopaedic surgeon, prosthetist, and orthotist.
may initiate much of the training that is finalized with
the physical therapist. DESCRIPTION OF ALGORITHMS, DIAGNOSTIC
TESTS. AND METHODS OF TREATMENT
Orthotist
GRADE ZERO FOOT
In some centers, the orthotist has assumed respon-
sibility for all therapeutic shoework. Relief of stress With an intact skin, the major emphasis is on the
and spreading pressure evenly over the whole foot prevention of open lesions (Fig. 12). If the patient has
are accomplished with toe blocks, ankle-foot orthoses claudication or rest pain, treatment is requested from
(AFO), sole stiffeners, rocker-bottom soles, and the vascular and medical services. These symptoms
foamed plastic inserts. are usually characteristic and the diagnosis is made
foot & Ankle/Vol. 2, No. 2 THE DYSVASCULAR FOOT 71
GRADE ZERO
SKIN INTACT
MEDICAL ADVICE -
EDUCATION
FOOT CARE.
I GOOD FOOTWEAR I
SURGICAL CORRECTION
CLAW TOE REPAIR
RESECT BONY
PROMINENCES
Fig. 12. Algorithm for Grade Zero foot, no open lesions.
by eliciting a good history and confirming it with phys- suggest that vascular disease is minimal or lacking.
ical examination and simple noninvasive t e s k 4 ’ However, metatarsal and digital arteries distal to the
Pain, if present, may be an ache, cramp, or discom- arcuate vessels may be involved and ischemic toe
fort that stops after walking a given distance. Relief problems may be co-existent with bounding dorsaiis
comes when walking ceases. After a short rest, walk- pedis and posterior tibia1 pulses. In the absence of
ing can continue. With progression of the disease, the these pulses, the more proximal pulses must be eval-
pain-free walking distance shortens. The patient then uated.
may experience pain even at rest. In addition to the defects caused by arteriosclerosis,
The pain then is at the area most distant from the the diabetic patient has the defect of basement mem-
heart, usually the forefoot and midfoot. When the brane thickening.2.54, 5 5 It involves the capillaries and
patient is sleeping, cardiac output decreases, and the probably the immediate postcapillary venules in all of
pain may intensify. Blood flow to the foot may be the systems of the body. It appears to cause a diffusion
increased and some relief may be obtained by sleep- defect rather than occlusion.‘ Some studies have
ing in a chair or hanging the leg over the side of the shown increased passage of substances across the
bed. Some patients have such little cardiac reserve involved vessels. The exact pathological effect of this
that further treatment, other than analgesia, is not thickening has been difficult to measure. There ap-
indicated. Physical examination may reveal the pres- pears to be a difference in the ischemic index healing
ence of vascular disease. Inspection may show atro- levels between the diabetics and nondiabetics. The
phy of muscle, loss of subcutaneous fat, and cessation 0.10 difference between 0.45 of the diabetic and 0.35
of nail and hair growth. The skin becomes pale and of the nondiabetic is postulated to be due to the
cracks easily. The presence of pedal pulses may capillary basement membrane thickening.
72 WAGNER Foot & Ankle/Vol. 2,No. 2
Noninvasive evaluation of the arterial tree of the is the same as the transmitted signal, and zero Doppler
lower extremity has been most satisfactorily carried effect results. In Figure 13C, collateral flow has re-
out with Doppler ultrasound. stored full venous flow and a Doppler signal again
results.
Doppler Ultrasound and the Ischemic Index The electronic circuitry receives the signal, com-
pares it with the transmitted signal, and expresses the
In recent years, transcutaneous Doppler ultrasound difference audibly, visibly, or on a printed strip. Alter-
has been used to measure arterial flow patterns, to ations in the audible signal vary with the degree of
assess blockage of the arterial circulation and venous stenosis and with patency of collateral channels. With
drainage system, and as a sensitive stetho- a little practice, these changes can be recognized.
scope,6. 8 . 21. 26, 32.41.6 7 , 7 2 . 7 3
Its major use as a stetho- The “water hammer” effect can be heard near the
scope has been to measure systolic pressure in the site of arterial obstruction. As the probe nears the
leg and to map the arterial tree. The main element is block, the sharpness of the sound increases up to the
the transducer, or probe, with transmitting and receiv- point of complete block, where all sound disappears.
ing piezoelectric crystals (Fig. 13). Ultrasound waves In areas of poor collateral flow, a hollow “wind tunnel”
in the range from 5 to 1 0 megahertz (MHz) are effect is heard.
beamed into the limb from the transmitting crystal. A Mapping of the arterial tree can be done almost as
frequency near 5 MHz is sufficient to measure large accurately as with an arteriogram (Fig. 14). The site
arterial trunks and venous flow. A probe with 9 to 10 and degree of blockage can give some clue as to the
MHz is better able to pick up signals from smaller type of revascularization possible. Systolic pressures
vessels, such as those in the dorsum of the foot and are taken at the same time (Fig. 15). The American
in the toes. A coupling gel is necessary on the skin as Heart Association recommends that the width of the
the waves are rapidly attenuated in air. Each tissue sphygmomanometer cuff should be 120% of the di-
interface of different density reflects a portion of the ameter of the limb being Thus, a 6-inch
wave. The reflected waves are changed in frequency cuff would be used on a 5-inch calf. A child’s cuff
in proportion to the velocity of the moving surface. suffices for the midfoot. Cuffs made from a Penrose
Figure 13 demonstrates the use of Doppler ultra- drain or a plethysmograph cuff do well for the great
sound to trace a thrombosis in the popliteal vein. In toe (Fig. 16).
Figure 13A, the reflected signal is changed in fre- The systolic pressures obtained are used to calcu-
quency by the velocity of the moving cells. In Figure late the ischemic index. Each lower extremity pressure
13B, the clot has blocked the flow, the reflected signal is divided by the brachial artery pressures. In Figure
*TO AMPLIFIER
I
ULTRASOMC PROBE -~
POSTERIOR
/ TlBlAL
A POPLITEAL
VEIN
CRYSTAL TRANSMITTING
NORMAL DOPPLER SHIFT NORMAL DOPPLER SHIFT
Fig. 13. Doppler ultrasound used to trace thrombus in popliteal vein. Note no Doppler .shift with no flow, View B
ISCHEMIC INDEX In order to determine the efficacy of the index, 71

surgical procedures were performed in which the in-
R L dex had been measured but was unknown to the
BRACHIAL ARTERY PRESSURE 140 140
CALF/ARM RATIO 70/140 050 I operating physician. The site of amputation and type
of surgical procedure were chosen on clinical grounds
only. When the series had been completed, it was
found that all but one of the failures had been pre-
dicted by the index (Figs. 1 7 and 18). The cutoff point
appeared to be 0.45. That figure has now been used
in all diabetic patients. Table 1 represents a consec-
utive series of 277 cases with an index of 0.45 in
diabetics and 0.35 in nondiabetics. It is postulated
that the 0.10 difference is due to basement membrane
thickening in the diabetic. A total success rate of 96%
was obtained in this series. Surgical procedures
ranged from incision and drainage of foot lesions to
-
3 8 3 major lower extremity amputations.
Gangrene Some patients have medical calcinosis or Moncke-
berg's medial sclerosis resulting in pipestem arteries.
Fig. 14. Map of arterial tree and systolic pressures recorded with
Doppler ultrasound. Note low pressure distal to occlusion. Ischemic It is difficult to compress these vessels with a blood
index IS calculated by dividing lower extremity pressures by arm pressure cuff and the resultant systolic pressure in
pressure. the leg is always higher than that in the arm. The
ARM B P = 120 rnrntig 0 HEALING

o FAILURE
80 mmt
\ TRANSMETAT
LISFRANC
AKA TKA BKA SYMES CHARCOT TOES
,-..
I"
Fig. 15. Pressure cuff in lower thigh inflated. Note block in super- E
ficial femoral artery. Systolic pressure is 80 mm Hg below the block. -E
Ischemic index equals 80 m r n / l 2 0 rnm = 0.67. $ 150 - 0
3 0
V
J
VJ 0
W
LL
a
Fig. 16. Plethysmograph cuff used to obtain pressure at big toe.
14, the blockage is in the superficial femoral artery.

The index is 0.50, i.e., 70 + 140 mm. This indicates
-PROXIMAL DISTAL CALF ANKLE MIDFOOT TOES
roughly that one-half of the flow is passing the blocked THIGH THIGH
area. Of all of the simple noninvasive tests, the is- BLOOD PRESSURE SITE
chemic index derived by Doppler ultrasound has pro- Fig. 17. Blood pressure taken in 71 consecutive diabetic cases
vided the most useful set of numbers to be used in the with foot infection or gangrene. Failures occurred below 70 mm Hg
management of the dysvascular limb in our institution. systolic pressure.
0 HEALING we have not had a failure where the ischemic index
0 FAILURE
TRAN SMETAT was over 1.0. Surgery has been performed at the
LISFRANC lowest level indicated by viable skin and absence of
CHARCOT
AKA TKA BKA infection.
In other centers, absolute Doppler pressure had
been used to predict healing. In still others, clinical
criteria supplemented by angiography have been
used. The references numbered should provide a wide
spectrum of ideas,6-8,21. 2 6 . 4 8 . 72. 73
Vascular Procedures
Although this review is not intended to teach vas-

cular surgical techniques, it is important that physi-
cians caring for dysvascular foot problems recognize
that vascular surgical procedures are available for
correction when medical and other nonoperative treat-
ment has not been successful.", 2 2 . 38. 39. 59 A series of
Q I illustrative cases will show areas of blockage and the
resulting wave forms and pressures.
0.3 Figure 19 represents a normal examination with
systolic pressures of 120 mm Hg throughout the ar-
2 0.2 terial tree and normal wave forms.
(L
a Figure 20 shows a partial obstruction of the com-
0.1 mon iliac artery that does not reduce the pressure
distal to the block, but does change the wave form.
PROXIMA ANKLE MIDFOOT Right hip and back ache can be presenting symptoms
THIGH
due to local small vessel blockage.
INDEX SITE
Figure 21 shows the common iliac artery blocked
Fig. 18. Ischemic index calculated in 71 consecutive cases with
more than in Figure 20. The ischemic index has been
foot infection or gangrene. Note no failure with index over 1 .O.
Failures occurred at levels below 0.45.
TABLE 1
277 Consecutive Cases of Infected or Gangrenous Foot
Problemsa i\ A ARM
Healing Rate (YO)
No of ~ _ _ _ _ ~_ _ ~~
Level
Procedures Com-
Diabetic Nondiabetic
bined
~~
AK 29 88 100 93
TK 25 100 100 100
BK 49 95 88 92
Syme's 79 87 95 91
Transmet 21 100 100 100
Ray 33 81 100 91 KNEE
Toe 30 100 100 100
I&D 11 100 100 100
__ ~
Total 277 93 98 96 KNEE

a Ischemic index above 0.35 in nondiabetics and above 0.45 in
diabetics.
ischemic index is, thus, over 1 .O. In cases of this type,

surgery has been planned wherever pulsatile flow is
heard, the skin is suitable for flaps, and there is no
gross infection at the site of amputation or operation.
In Figure 18, nine cases had an index over 1 .O. All of
I
L 120
Fig. 19. Normal Doppler pressures and wave forms. Arm pres-
these healed. Since our first use of the index in 1975, sures equal to leg pressures.
J1,,J1, ...
...
......
.' ...
+
0
2
1 ..s::.. .
..::.._,
.i..
::::i:...;.
=
=
-==
+
!
I20 THIGH
I20
ABOVE KNEE
120 ABOVE KNEE
BELOW KNEE
I20
ANKLE
120 120
I20 I:, A& 120

70 A
s1,
...
,j
:::::,::. , ., 120
Fig. 20. Common iliac artery, partial block. Leg pressure not
decreased. Fig. 22. Complete block of common iliac artery. Significant reduc-
tion of leg pressure.
k,& ..:..
12+r
2 .....
.L..
...........:.
.I..
J&
80
THIGH
I20
80 ~ J1, 120 ABOVE KNEE
80
BELOW KNEE ABOVE KNEE
,?,,,.: 120
80
A ..:.:..
..:.:.
...:::*...:.......>(
ANKLE
I20
80 f\L, .:.......................
120
Fig. 21. Common iliac artery almost completely blocked. One-

third reduction of leg pressure.
70 . A ,..<:c.:
.A ..!.. 70
Fig. 23. Complete block at bifurcation of the aorta. Full-blown
Leriche's syndrome. Distal supply by collateral circulation.
reduced to 0.67. Mild symptoms of claudication may

be present. following endarterectomy and other vascular recon-
Figure 22 portrays a complete block of the common structive procedures.
iliac artery. The pressure below the block has de- Figure 24 presents blockage of the superficial fem-
creased to 70 mm and is supplied by collateral circu- oral artery, producing lowered systolic pressures and
lation as shown by the wave forms. The ischemic altered wave forms distal to the blockage. Tissue
index is 0.58, indicating sufficient flow for tissue via- viability is not in danger but other evidence of loss of
bility. The patient, however, has claudication in the circulation is usually present. Mild calf claudication
lower back muscles, hip, and upper thigh. Vascular may be present. Vascular reconstruction of larger
reconstruction is highly successful with this type of vessels is usually successful.
segmental disease. Figure 25 shows blockage of the popliteal artery
Figure 23 demonstrates the full-blown Leriche's but with good collateral circulation still allowing tissue
syndrome. Although there is sufficient collateral flow viability despite altered flow and wave forms. Symp-
for tissue viability (ischemic index 0.581, there is clau- toms of claudication and atrophy of tissue are usually
dication, atrophy of dermal appendages, loss of libido, present. This area is at the lower limits of successful
and markedly altered flow wave. With highly localized endarterectomy, and bypass surgery is more suc-
disease, return of sexual potency has been reported cessful.
I20
st,
& ......
THIGH
I20
70 J-L ABOVE KNEE 80
~ \
Ji, ABOVE KNEE
I20
BELOW KNEE
70 A BELOW KNEE .:....
.
..... I20
80
ANKLE
40 I20
70 40 I20
I20
Fig. 24. Complete blockage of the superficial femoral artery Fig. 26. Blockage of superficial femoral artery and trifurcation
Amenable to endarterectomy below the popliteal artery.
BELOW KNEE
30 A
70 _/L &, ..... 1 2 ~

30 . I20
Fig. 25. Complete blockage of the popliteal artery above the Fig. 27. Blockage of femoral, popliteal, posterior tibial. anterior
trifurcation. May have only mild claudication. tibial, and peroneal arteries.
Figure 26 illustrates blockage of the trifurcation grafts are now being tried in attempts at limb salvage,
added to superficial femoral artery occlusion. Two- but the long-term patency rate is still low.
level disease produces severe decrease in ankle and Vascular Surgery. Surgical correction of athero-
foot flow. This will maintain the tissues as long as the sclerotic lesions has improved markedly in the past
skin is intact. In the diabetic, arteriosclerotic rest pain 20 years. Over 70,000 peripheral vascular recon-
begins with an index around 0.30. Open injuries may struction procedures are performed each year. Al-
heal with prolonged local treatment, but in general though contrast angiography is not needed to confirm
healing does not occur with an ischemic index below the presence or absence of arterial disease, it is used
0.45 in the diabetic. to determine the location and extent of the disease
Figure 27 shows a blockage of a degree which when vascular reconstruction becomes necessary.
leads to an ischemic index of 0.25. Rest pain is usually Angiography. Visualization of the arterial tree by
moderate in the arteriosclerotic. In the diabetic, there radiological means is an essential preliminary step to
may be enough peripheral neuropathy that the pain is revascularization procedures. Intra-arterial injection
not troublesome. Any open injury does not heal. Re- of contrast materials such as Hypaque M, Renograffin,
vascularization procedures are nearly impossible and Angio-conray, and Conray is followed by X-ray ex-
amputation usually results. Small subcutaneous vein amination at intervals determined by the information
f o o t & Ankle/Vol. 2, No. 2 THE DYSVASCULAR FOOT 77
A
sought. The radiopaque material contrasts well with
the surrounding tissues and produces quite an accu-
rate picture of the arterial areas of atheromatous
deposits, aneurysmal dilatations, stenosis, and occlu-
sion, and then of the venous pick-up and return flow.
Thus, the angiogram is a “road map” to delineate
areas of occlusion, degree of collateralization, degree
of damage to the traumatized artery, and areas of
aneurysmal dilatation. In general, the tests should be
ordered by the vascular surgeon when the decision
has been made that vascular surgery is necessary.
The quality or degree of flow to an area cannot be
determined from the angiogram. However, it is of
value in determining patency of distal vessels for
bypass procedures.
Angiography is not without some hazards. Allergic
response to media, local extravasation of media, injury
to the arterial wall, thrombosis of the tested vessel,
infection at the injection site, bleeding, vasospasm,
and more seriously, renal failure, have all been en-
countered as complications. Continued improvement
of contrast media, refinement of instruments, refine-
ment of techniques, and increased training of person-
nel have all combined to reduce the complications to
an acceptable level.
The decision finally must be made for the type of
revascularization procedure to be performed. End- Fig. 28. Involvement of aorta distal to renal arteries and of com-
mon iliacs and common femorals down to profunda femoris.
arterectomy, embolectomy, profundaplasty, or bypass
graft are all indicated with suitable prerequisites. By-
pass procedures are most successful when performed
with venous autografts.”. 38. 39 However, in the ab-
sence of a suitable vein graft, synthetic grafts have a
sufficiently high success rate that they are now being
used.*‘
The following diagrams outline a series of vascular
procedures that are performed after angiography has
aided in the determination of the site and selection of
the type of surgery.
Figure 28 is a drawing from an angiogram showing
atheromatous involvement of the aorta distal to the
renal arteries and involving the iliacs and femorals
down to the profunda femoris. The involvement is too
severe to be corrected by endarterectomy.
Figure 29 represents two methods of grafting from
the aorta to the common femoral arteries. In Figure
29A the graft is attached in an end-to-side fashion,
leaving the diseased segment in place. This has the
advantage of leaving small collateral vessels in place
with the possibility of increasing flow to the tissues
supplied by them. In Figure 29A the major diseased
segments are excised the same as when aneurysmal
defects are present. The aorto-graft anastomosis is
direct. Excision has the disadvantage of leaving some Fig. 29. Aortofemoral bypass grafting. A , without resection of
areas with lessened flow. There is slightly less chance diseased vessels, B, with resection of diseased vessels, usually
of thrombosis with the direct anastomosis, and less aneurysmal.
78 WAGNER Foot & Ankle/Vol. 2, No. 2
chance for false aneurysm which does occur in end-

to-side anastomosis.
Other revascularization procedures in the larger
vessels of the abdominal area are possible, such as
endarterectomy or bypass graft. In general, proce-
dures in the larger vessels of this area are over 90%
successful. Success means restoration of flow and
salvage of the dysvascular limb by healing of the
presenting lesion, cessation of claudication or rest
pain, or healing of a foot lesion with local surgical
procedures or minor amputations.
For a block in the common iliac areas, a bypass can
be performed from aorta to femoral artery (Fig. 30).
Femoro-femoral cross graft is quite successful when
there is patency of the opposite common iliac artery
(Fig. 31). When the blockage is lower and the revas-
cularization must be performed in the smaller vessels
in the thigh and popliteal area, the success rate drops
to 60 to 70%. Probably the most common procedure
performed is the femoral-popliteal bypass graft using
a reversed saphenous vein. When suitable vein grafts
Fig. 31. Femoro-femoral bypass with open contralateral common

iliac.
are not present, Dacron, other synthetic grafts, or

stabilized human umbilical vein grafts are used. Ex-
cept for the aortic portion, this is similar to the graft
shown in Figure 32, which is of Dacron. For segmental
disease, segmental bypass grafts are available in
many patterns. An excellent example is the aorto-
femoral-popliteal graft (Fig. 32).
If suitable grafting sites are not available due to
infection or a previously failed graft in the aorta,
axillofemoral bypass grafting or other extra-anatomic
procedures are possible.
At times there is such extensive disease in the area
below the trifurcation that revascularization is not pos-
sible (Fig. 33). Some centers are now placing subcu-
taneous vein grafts into ankle and foot vessels in
attempts at limb salvage. Some early success has
been achieved in allowing an ulcer to heal but long-
term patency has not yet been realized.
Graft Materials. Autogenous saphenous vein-re-
versed, or in situ with fracture of valves, appears to
Fig. 30. Right aortofernoral bypass. Partial obstruction of left be the most satisfactory source of graft. If the vein is
common iliac may require later endarterectomy or bypass. not available, other materials have been developed.
profunda femoris artery supplies the major portion of

the thigh. It is occluded in fewer patients than is the
superficial femoral. Stenotic lesions are present in up
to 60% of ischemic patients and are more common in
diabetics. Most stenotic lesions are localized to the
proximal portion. Profundaplasty can revascularize an
extremity with excellent relief of claudication and ad-
vanced ischemia. It is possible to restore a pedal
pulse, even with a completely blocked superficial fem-
oral artery. The profunda femoris artery also may be
used as the source for the bypass to the popliteal
artery.59
If the patient has been active and ambulatory prior
to entering the hospital with a painful ulcerated or
gangrenous foot, revascularization procedures should
be strongly considered. The mortality rate has steadily
declined in reconstructive vascular surgery (2-3%).
The mortality rate is now less than that reported for
major lower extremity amputations. However, it must
Fig. 32. Aortofemoral popliteal segmental bypass.
The list of unsatisfactory materials is long. New ones

are being tested daily. Dacron is the most often used
synthetic material at present. Silicone mandrils, and
polytetrafluorethylene are two new materials showing
promise. Processed bovine arteries and glutaralde-
hyde-stabilized human umbilical vein are among the
processed biological tissues in use.
In addition to bypass grafting, endarterectomy is
also useful to correct obstruction of the larger vessels,
such as aorta, common iliac, external iliac, and com-
mon femoral. It is excellent to use over short dis-
tances. Different methods of excision are advocated
in different centers, In arteries of decreasing size, the
arteriotomy may be closed with a patch graft to pre-
vent stenosis. Judging the upper or lower extent of
the endarterectomy and the need for a patch graft or
accompanying bypass obviously must come with ex-
perience. It may be combined with bypass grafting
around areas not suitable for endarterectomy. Fig. 33. Severe involvement of the trifurcation below the popliteal
Profundaplasty is excellent for selected cases. The artery. Not amenable to bypass surgery in most instances.
be pointed out that many patients undergoing above right leg. Amputation was indicated only at the hip
the knee amputations are ill because of the amount of disarticulation level. Despite the low pressures and
infected gangrenous tissue involved and because of indexes on the left, the patient had no pain and there
the degree of cardiovascular disease. Most of them were no open lesions. It has been stated by others
are not suitable patients for lower amputations, even that it appears to take more blood to heal an open
with revascularization. At Rancho Los Amigos Hospi- lesion than it does to keep an intact limb alive.7'
tal, the perioperative hospital mortality is less than 1 Yo Angiography was performed and bypass grafting
for all amputations at or below the knee. The mortality done. A Doppler examination performed 3 weeks later
rate is 9% for above the knee amputation^.^' All of revealed a patent aortofemoral popliteal graft to below
these patients are elderly and ill with infection and the bifurcation (Fig. 35). There was minimal loss of
gangrene. Virtually none have been suitable for revas- pressure down to the midfoot. The ischemic index was
cularization procedures and most are not prosthetic 0.58 at the midfoot. The patient underwent a trans-
candidates. metatarsal amputation that healed well (Fig. 36).
An excellent example of the rehabilitation possible In addition to chronic vascular changes from dis-
through revascularization is the case of a 75-year-old, ease and degeneration, acute and chronic changes
hypertensive, diabetic male referred for gangrenous may result from trauma of all kinds. If arterial repair is
changes of the toes of the right foot. Doppler exami- not available because of a lack of trained personnel
nation (Fig. 34) revealed occlusion of the right com- or the injury is not repairable, amputation becomes
mon iliac artery and stenosis of the left common iliac necessary. A basic principle is to save all length
artery. The right superficial femoral artery was com- possible and then revise as necessary.
pletely occluded. There was tibial-peroneal artery in- A 21 -year-old male fork-lift truck driver was pinned
volvement in both calves. The ischemic index was beneath his overturned truck. His foot was caught by
0.45 at the right hip and well below that in the distal a projecting part of the truck. All of the neurovascular
-1
-TKA I TKA a
3
-BK -BK o m
SYMES -SYMES 3:
-MIDFOOT -MIDFOOT S a
I L K
-TOES -TOES
~.
YASCUI AR SVRGFRY RFCONSTRVCTION
m: VESSEL PATENCY (+=OPEN,
-=CLOSED, SrSTENOSIS)
RIGHT LEFT
?
1 K;
POPLITEAL A .
ANTERIOR TlBlAL A .
POSTERIOR TlBlAL A. (i) fz) 17
DISTAL "RUN-OFF:" GOOD
ISCHEMIA
%&- f l J 2 (-) NON-PULSATILE FLOW

CLINICAL PHY.$IO'LOGIST .8 8 FLOWPRESSURE NOT DETECTED
VASCULAR EVALUATION SERVICE
ROOM 106, CLINIC BLDG.. RLAH
Fig. 34. Severe iliac, femoral, and tibia1 involvement on the right with gangrene of the toes. Less severe on the left. Healing level at the hip
on the right if surgery performed for the gangrenous toes.
VASCULAR EVALUATION STUDY REVEALED 02 . ~ F F C L ~ ~ C NAME

RLAH # / t Z i r ~
WG & DATE +~lb ____
- .
WOUND HEALING LEVEL (PHYSIQIOGIC)

FiKitu E T
R B A = x L BA=-
-AK - AK
>- *
t
-TKA -TKA
-BK -BK
-SYMES -SYMES
-MIDFOOT -MIDFOOT
LTOES *= -TOES
VASCULAR S R G F R Y RFCQPEBJJ"
DP;TA. VESSEL PATENCY (+=OPEN,
-=CLOSED, S=STENOSIS).
RIGHT LEFT
POPLITEAL A
ANTERIOR TlBlAL A
DISTAL "RUN-OFF:"
____ ___
GOOD
FAIR
POOR
ABSENT
___ -
1 -
GOOD
FAIR
POOR
ABSENT
- ____
ISCHEMIA (ANKLE 1. NONE NONE
MILD
MOD
SEVERE
PROFOUM
IMP
GANGRENE
COMMENTS * f / D E Q ~ A B FLPP cL051)et r ( 3 ~ ) c
__-
I/SSJ€-/J _ed&Pu=
(- 1 = NON-PULSATILE FLOW
-8 = FLOWPRESSURE NOT DETECTED
VASCULAR EVALUATION SERVICE rr a p Or 316 73 +f 5 , .o 6'7s /-3
ROOM 106, CLINIC BLDG , RLAH - ~ /omm.Y

Fig. 35. After bypass grafting of patient in Figure 34. Patent segmental graft to aorto-fernoral-popliteal-trifurcation areas. Healing level now
in rnidfoot.
tibia. A KritterZ7drain was used to irrigate the wound

(Fig. 39). The patient is now a successful prosthetic
user.
An 18-year-old car-wash attendant caught his foot
in the chain drive and sustained a crush and pene-
trating injury to the medial arch area. It appeared to
be apparently minor at the time of injury. Dry gangrene
gradually developed following thrombosis of the pos-
terior tibial and dorsalis pedis arteries (Figs. 40 and
41 1. Before referral, a below the knee amputation had
been planned. After Doppler evaluation showed good
pulses to the edge of the gangrene, a classic Syme's
amputation was performed. The gangrene ended 5-
mm distal to the edge of the flap. A Shirley two-lumen
Fig. 36. Early healing of transrnetatarsal amputation after bypass drain was used to irrigate and drain the cavity (Fig.
grafting for severe involvement of iliac, femoral, tibial vessels. 42). The patient is now a successful prosthetic user.
In his convalescent period, he obtained training in
structures were crushed beyond repair (Fig. 37). X- prosthetics and now is a successful employee of a
rays showed complete disruption of all osseous struc- prosthetic shop.
tures in the ankle and heel area (Fig. 38). The wound The preceding examples have been those of vas-
was filled with foreign material. In surgery, a posterior cular problems repairable by surgical procedures, or
lateral flap was fashioned that covered the end of the if not repairable, have been solved by amputation of
competent distal valve closed, the blood is forced

upward. There are similar valves in the lymph system
and lymph fluid is forced upward with muscle contrac-
tion. When a walking cast is applied over minimal
padding, it appears to aid in control of edema by its
close application to the skin. Pressure against the soft
tissues forces fluid upward and appears to reduce
interstitial edema.
The case of a 70-year-old nondiabetic is illustrative.
The patient had severe rest pain in the right calf and
was admitted for a vascular work-up. His ischemic
index at the calf level was 0.30. There were no open
lesions. Angiography (Figs. 44-47) showed clear
renal arteries, aneurysmal dilatation of the abdominal
aorta and common iliac arteries, and obliteration of
the superficial femoral and popliteals with poor run-
off. It was felt that no revascularization was possible.
A below the knee amputation was suggested and
agreed to by the patient. On the day of the scheduled
amputation, the alternative procedures were again
discussed with the patient, and walking-cast treatment
was suggested. The patient agreed and amputation
was cancelled.
Fig. 37. Fork-lift truck injury to foot with complete destruction of

neurovascular bundle.
Fig. 38. X-ray examination showing complete loss of bony conti-

nuity, severe soft tissue disruption, and foreign material in wound.
the involved part. There are patients with rest pain

who may respond to walking-cast treatment. The ex-
act relief mechanism is not known, but it is postulated
that it is related to the musculovenous pump mecha- Fig. 39. Nonstandard posterior lateral flap in Syme's amputation.
nism (Fig. 43). As the muscle contracts, it squeezes Kritter-type irrigation of wound. The patient is now a prosthetic
the vein. Blood in the vein is compressed, and with a user.
patient was walking several blocks a day. At 3 months,

an ankle-foot orthosis with an anterior tongue was
fabricated (similar to Fig. 84). The Doppler index was
0.50 at this time. One year after the cast treatment,
the ischemic index had risen to 0.70. An angiogram
Fig. 42. Immediate postoperative condition. A Shirley two-lumen

Fig. 40. Plantar view of foot after crush injury. Progressive throm- tube is used for irrigation and drainage of the cavity of the wound.
bosis of plantar vessels. The white tube contains the irrigant. The larger tube contains bloody
drainage from the open bone and goes to gravity rather than
suction.
Fig. 41. Dorsal view of foot with gangrene of most of forefoot

Progressive thrombosis of dorsal vessels
With the application of the first cast, over 50% of LATERAL CHANNE
the rest pain was alleviated. The second cast was
applied at 1 week. The third cast was applied at 3 Fig. 43. Musculovenous pump mechanism that aids in return of
weeks. At this stage most of the pain was gone. The blood and lymph to the right side of the heart.
Fig. 46. Patchy involvement of superficial femoral arteries with

complete block.
Fig. 44. Abdominal portion of angiogram showing clear renal

arteries and aneurysmal dilatation of the distal aorta. Patient has
claudication and rest pain on the right.
Fig. 47. Poor collateral flow and poor run-off from superficial
femoral artery distally.
is planned at 18 months. Similar results have been

obtained in other patiertts but none have been willing
Fig. 45. Small aneurysm of right common iliac artery and moderate to undergo another angiogram for the sake of dem-
involvement of walls of common femoral arteries. onstrating what area of circulation has been improved.
Neurological Procedures heads (Figs. 1 4 0 and 141). Pressure from shoes and
ground reaction forces then lead to hyperkeratotic
Continuing down the algorithm from vascular symp-
areas. Shear pressures produce breakdown of the
toms and the vascular service, the area of neurological
symptoms is reached. The greatest association of layers of the dermis. Because of lessened sensation,
the patient is unaware of the breakdown and, for
dysvascular and neurological pathology is in the dia-
betic population,%1 3 , 14.16. 30.45,62 There are other dis- many, the first sign of a problem is moisture on the
stocking at the end of the day. Progression of this
eases that are similarly affected.63 Patients with men-
lesion produces most of the problems in the dysvas-
ingomyelocele, tabes dorsalis, aplastic anemia, alco-
cular insensitive foot.
holic polyneuropathy, hypertensive neuropathy,
Neurogenic arthropathy appears to be increasing in
heavy metal poisonings, and scleroderma may have a
frequency or is being recognized more often in the
similar association of neuropathy and vasculopathy.
dysvascular foot, associated with diabetes or other
Medical treatment of neuropathy is varied and difficult
neurological p r o b l e m ~ . Bone
'~ changes range from a
unless an exact, treatable cause is found. During early
mild osteopenia to loss of major substance to a severe
onset in the diabetic, there is some evidence that strict
destruction of most of the midtarsal joints. Loss of
control of the blood sugar can lead to remission of
mineralization may be the only finding, but may also
symptoms. However, when fine neurological testing is
be associated with more destructive changes (Figs.
performed, it is found that all diabetics who have had
48 and 49).
the disease for 20 years have signs or symptoms of
neuropathy. Fractures
All types of medical treatment have been used and
some have had spectacular success in an occasional Spontaneous and pathological fractures are com-
patient. None have helped in large series. Biochemi- mon and may not be discovered until X-rays are taken
cal, metabolic, or vascular alterations have all been to ascertain the reasons for midfoot swelling. Frac-
implicated as precipitating causes in different theo- tures may also occur with minimal injury. Figures 50
ries,9,16,1 7 . 2 0 . 4 5 . 6 2 However, none of the theories have and 51 depict the foot of a 50-year-old diabetic injured
helped in the production of a successful treatment
regime.
Early laboratory findings are those related to de-
myelinization. Delays in conduction velocity and signs
of motor disturbance can be found as early as 2 years
before the patient has symptoms. In siblings of dia-
betics, similar derangements are found, sometimes
before alterations can be measured in the blood glu-
cose control. Symptoms of nerve involvement in the
foot and ankle can vary from severe pain to complete
numbness with all the variations and dysesthesia in
between. It is interesting that the highest percentage
of patients with complaints relating to hypersensitivity
are seen by the internist and neurologist. The highest
percentage of those with hypoesthesia attend the
orthopaedic clinics, as they have most of the ulcera-
tive and infectious problems. There seems to be no
relation between severity of diabetes and severity of
neurological findings.
Involvement of the motor nerves leads to weakening
of various groups of muscles. The patients may com-
plain of feelings of weakness when muscle testing
would suggest virtually normal function. The common
peroneal nerve appears to be one of the peripheral
nerves most commonly affected. Weakness of ankle
dorsiflexion may be sufficient to require a dropfoot
brace. Weakness of the intrinsic musculature of the
foot predisposes to clawtoe deformity. This, in turn, Fig. 48. Loss of mineralization in metatarsal heads. Punched-out
leads to bony prominences on the dorsum of the lesion in fifth metatarsal head, a characteristic finding of Charcot
interphalangeal joint and depression of the metatarsal degeneration.
Fig. 50. Fractures of second and third metatarsals from mild

Fig. 49. Complete destruction of first and second rnetatarsopha- sprain. Injury of cuneiform metatarsal joints not diagnosed at onset.
langeal joints. Note ground glass appearance of phalanges, healing
ot first metatarsal head, and maintenance of semblance of joint Figure 52 shows the right foot of a 27-year-old
spaces. woman with juvenile-onset diabetes. Disruption of the
talonavicular cuneiform area followed a minor sprain.
with a mild sprain. Disruption at the base of the first During walking-cast treatment, she was able to con-
and second metatarsals was not appreciated at onset. tinue working as an office employee. Healing of the
After prolonged casting, the degree of healing along area is confirmed by lack of swelling, lack of local
the first metatarsal shaft shows that Lisfranc joints heat, and restoration of outline of the navicular cunei-
were involved. form (Fig. 53). Protection of this foot must continue
Charcot breakdown of the midfoot may start spon- for the rest of the patient’s life. A polypropylene or-
taneously, may follow a mild sprain, or may follow a thosis has been constructed with the trimline just
surgical procedure such as toe and ray resection for behind the malleoli to allow about 20” of ankle motion.
an infected ulcer under a metatarsal head.” In the Medially, the slightly thickened area over the naviculo-
acute phase, heat, redness, and swelling may be cuneiform is protected by heating the polypropylene
present in the foot and leg. We have seen many and pushing the area out. The dent is filled with
patients treated for weeks as an infection or phlebitis Plastazote@’or a similar material (Fig. 54). The brace
until an X-ray finally showed the basic problem to be is comfortable and easy to wear (Fig. 5 5 ) .
in the bones and joints of the foot. Because of the insensitivity, some patients accept
With immediate casting and rest, the heat, redness, the deformity until it is beyond any treatment except
and swelling rapidly decrease. Casts are changed at amputation or major bone excision (Fig. 56). This foot
weekly intervals until the foot area is cool. Weight- is completely dislocated at the midtarsal joints. The
bearing casts are then used until signs of healing are major weightbearing area has now become the rem-
present by X-ray. Maturation of callus and remineral- nant of the navicular (Fig. 57). Because of the ulcer-
ization of the bone will occur with proper protection. -
The foot is then protected with an orthosis or shoe ‘”” Bakelite Xylonite Limited, distributed by Apex Food Products.
inserts for the rest of the Datient’s life. New York, New York.
f o o t & Ankle/Vo/. 2, No. 2 THE DYSVASCULAR FOOT 87
Fig. 52. Charcot disruption of the naviculo-cuneiform area of right

foot. Note fuzzy callus showing early healing.
Fig. 51. After cast treatment, amount of healing shown reveals full
extent of injury. Note marked callus at both second and third
metatarsal shafts and especially at base of first metatarsal.
ation which is infected, it is difficult to distinguish X-

ray changes of arthropathy from those of infection.
Amputation at the Syme's level versus talectomy has
been the usual choice for this degree of deformity.
If the final healing of the arthropathy has left an
unstable foot, arthrodesis can be performed. Just as
prolonged casting and bracing are necessary for heal-
ing of the arthropathic breakdown, so is prolonged
casting necessary to obtain surgical fusion.
A 59-year-old woman accountant had a Charcot
breakdown of both feet secondary to diabetes (Fig.
58). The right one healed in an acceptable position.
Despite cast treatment, the left one stayed in valgus
at the talonavicular joint (Fig. 59). The patient had
some pain and pressure areas medially below the
dropped arch. An ankle brace did not relieve the
deformity or the symptoms. She was constantly in
danger of breaking down the area of pressure at the
talonavicular joint. A triple arthrodesis was performed
with inset grafts and Staple fixation. The articular Fig. 53. Charcot changes after 1 year of cast and orthosis treat-
surfaces were not removed as more instability is pro- ment. Note restoration of cortical outline of cuneiform.
88 WAGNER Foot & A n k l e / V o / . 2,No. 2
Fig. 54. Polypropylene ankle-foot orthosis (AFO) for protection of

Charcot foot. Polyethylene foam fitted into depression at site of
naviculo-cuneiform bulge.
Fig. 55. Polypropylene ankle-foot orthosis (AFO) worn inside a
regular shoe. The patient wears slacks for most activities.
duced with bone removal. After cast removal, the
patient has continued with brace treatment for protec- Louisiana has excellent manuals on foot care which
tion of the midtarsal joints. Figure 60 shows the cor- were developed in connection with the care of the foot
rection of alignment of medial structures of the foot. in Hansen's disease.
Once a foot lesion has occurred, a recurrence is
Deformities
much more likely. Once a major amputation has taken
Following the algorithm from neuropathic symp- place, there is an increased chance for amputation in
toms, the diamond of foot deformities is reached. This the opposite limb and at one level higher."j Thus, it is
patient is "at risk" with or without deformities (Fig. important to make the patient or a member of the
61). Medical advice, education, foot care, and good family a part of the treatment team. Awareness of such
footwear are the foundations of preventive treatment. warning signs as an increase in size of a corn or callus
If the dysvascular patient with a Grade Zero foot has and increase in moisture from early breakdown over
no bony deformities or areas that appear to be of a pressure point must bring the patient in for a
concern to the physician, the patient is given instruc- checkup and treatment as indicated. A list similar to
tion and advice as to how to care for his feet. The the following is gone over with every patient.
ward nurses, liaison nurses, nurse practitioners, clinic The patient or members of the family should be
nurses, orthotists, and prosthetists all are engaged in instructed to:
the daily teaching of virtually every patient they con- 1 . Inspect feet daily for signs of any skin breakdown
tact. The patients are given booklets and are shown such as cuts, scratches, bruises, blisters, or cracks
short slide programs on the care of their feet. Local between the toes. If eyesight is poor, have someone
affiliates of the American Diabetes Association have else check.
excellent handouts on the care of the feet. The United 2. Wash feet gently each day with a mild soap. Dry
States Public Health Service Hospital at Carville, carefully, especially between the toes, blotting rather
dangerous. Fig. 58. Lateral standing X-rays. Charcot changes at talonavicular

6. Be Careful of chemical agents for the removal of joint on the left and at naviculocuneiform on the right. The right foot
corns and calluses. Check with your doctor. is asymptomatic. There is pain in the arch on the left.
7. Beware of bathroom surgery on corns and cal-
luses, particularly with razor blades. areas. Check by turning each shoe over each time it
8. Check the inside of shoes daily. Nail points, torn is put on to be sure no object is in it.
lining, bunched construction material, and even ac- 9. Avoid stockings that bind at toes or at the top.
cumulations of foot powder can produce pressure Watch for pressure from seams and darns.
90 WAGNER F o o t & A n k l e / V o l 2 No 2
Fig. 61. Healed residual Grade Zero foot following amputation of

lesser toes and metatarsal heads for gangrene and infection. Extra-
depth toe box provides room for toes elevated by the thickness of
the Plastazote insert
10. Check circular garters. They frequently pro-

duce sufficient pressure to act as a tourniquet. I!se ,A
garter belt if garters are necessary.
1 1 . Have your shoes fitted properly. Avoid pointed
shoes. If you have any clawing or hammering, obtain
shoes with a high toe box. Break in shoes over short
Fig. 59. Anteroposterior standing X-rays. Charcot changes at repeated episodes. Do not wear a new shoe more
talonavicular joint on the left and forefoot abduction. Charcot than 1 to 2 hr without checking for pressure areas on
changes at the naviculo-cuneiform joints but with acceptable align-
the feet until the shoe is broken in. This usually takes
ment on the right.
a week to 10 days.
12. Wear some footwear at all times. Your feet are
susceptible to cuts and scratches. Wear something
for protection even when getting up to go to the
bathroom at night.
13. Cut nails straight across. Do not cut into cor-
ners. At the first sign of redness or irritation, see you
doctor.
14. Be sure your feet are examined each time yoi
visit your doctor.
15. Advise anyone caring for your feet that yoi
have a vascular problem.
Bony deformities of the dysvascular foot are espe
cially prone to lead to callus, one of the first signs c
a pressure lesion. Continued pressure soon leads to
an open lesion. Protection with extra-depth shoes and
pressure-relieving inserts in the first line of defense.
The residual foot in Figure 61 is Grade Zero-there
are no open lesions. The original problem that re-
quired amputation of the lesser toes began with pres-
sure lesions on the second and third toes displaced
dorsally by the marked hallux valgus. Doppler is-
chemic index was over 0.45 and the operative wound
healed per primum. The patient is well protected with
an extra-depth shoe and a Plastazote insole. As the
Fig. 60. Triple arthrodesis of left foot with inset bone grafts and Plastazote begins to bottom, metatarsal pads are
staple fixation of talonavicular and calcaneocuboid joints. Note added proximal to the pressure areas visible on the
improved alignment on anteroposterior view. insole. With care, this foot should last the life of the
patient. If callus or ulcer should recur, prophylactic

surgery is indicated.
Prophylactic Surgery
Toenail procedures, bunionectomies, metatarsal

osteotomies, metatarsal head resections, claw and
hammertoe repairs, resection of bony prominences,
and arthrodeses can be done in Grade Zero feet when
the Doppler ischemic index is high enough.
The dysvascular foot is more susceptible to disease
and deformity of the toenails. Onychomycosis (fungal
infection) is common and leads to thickened nails and
nail beds. Pressure from the shoe onto the thickened
nail can produce inflammation which can then become
secondarily infected. This, in turn, can lead to gan-
grene which may require. major amputation. A chron-
ically ingrown nail can lead to the same sequence. A
ram's horn deformity, onychogryphosis, is usually
thick enough to cause similar pressure problems.
Complete removal of the nail and matrix is the best
solution. Two techniques have been used with suc- Fig. 62. Outline of incision for Syme's terminal amputation. Nail
cess: phenolization and the Symes terminal amputa- removed 2 weeks previously to allow infection to heal. Multiple
tion. These techniques can also be used on the lesser previous episodes of ingrown toenail. (Reprintea with permission
from Wagner, F.W., Jr.: The diabetic foot and amputations of the
toes. foot. In DuVries' Surgery of the Foot, 4th Ed. Mann. R.A. (Ed.) St.
fheno/ization- Technique. The nail is removed Louis, The C. V. Mosby Co., 1978.)
bluntly after local anesthetic block at the base of the
toe. A Penrose DrainB2is used at the base for hemo-
stasis. Concentrated phenol (86-90%) is painted over
the nail matrix and subungual tissue. The surrounding
skin is covered with petroleum jelly to protect it from
burns. The phenol is left for 1 min. It is then washed
off with 7 0 % alcohol or sterile water. The step is
repeated a total of three times. The patient is in-
structed to wash the nail bed daily with a soft brush
and soap to remove debris. An organic iodine solution
is used on the nail bed. The nail bed gradually gran-
ulates and epithelializes with no residual flaking. On
occasion, the tip of the toe will begin to curl up over
the end of the distal phalanx as the dorsal support of
the nail is lost. A wedge of soft tissue can be removed
if this becomes symptomatic.
Syme 's Terminal Amputation- Technique. Under
local anesthesia and with a Penrose drain for tourni-
quet control, an elliptical incision is made around the
nail and its matrix (Fig. 62). The soft tissue is removed
down to bone (Fig. 63). The distal tuft is exposed
subperiosteally, and the distal I - c m is removed to
Fig. 63. Nail matrix, subungual tissue, and ellipse of soft tissue
allow closure of the flap (Fig. 64). The tourniquet is
removed. Penrose drain for tourniquet control. (Reprinted with
released and hemostasis secured with electrocoagu- permission from Wagner, F.W., Jr.: The diabetic foot and amputa-
lation. A wick of iodoform gauze is used to allow tions of the foot. In DuVries' Surgery of the Foot, 4th Ed. Mann,
drainage of hematoma from the cut bone. Closure is A . A . (Ed.) St. Louis, The C. V. Mosby Co., 1978.)
with interrupted, nonabsorbably suture (Fig. 65).
Ambulation is allowed to tolerance in a wooden- soled surgical shoe. Healing to nontenderness may
take 6 to 8 weeks. Regular shoes may be worn when
swelling and tenderness allow. The case illustrated is
' Aloe Medical Company, St Louis, Missouri of a juvenile diabetic who had multiple episodes of
Metatarsal Head Removal-Hoffman Procedure.

Plantar ulcers respond beautifully to the removal of
the overlying metatarsal head through a dorsal inci-
sion. However, with single head removal, transfer
lesions may occur and the foot must be protected with
shoe inserts. Resection of all of the head is indicated
if there have been previous ulcers that healed and
recurred, if there are severe plantar keratoses, if other
heads are missing from previous surgery, if there is
severe pressure pain at the metatarsal head related
to neuropathy, or if severe disruption of other meta-
tarsophalangeal joints is present. The flares of the
proximal phalanges should be resected if they feel
prominent on the plantar surface after the heads have
been removed. This testing should be done in surgery
as a proximal flare has been the cause of subsequent
plantar ulcers.
Technique. A transverse or three longitudinal inci-
sions can be used, depending upon previous surgery
in the area, and the surgeon's previous experience.
The longitudinal incisions are made over the first,
Fig. 64. Distal tuft of proximal phalanx excised to allow flap
closure. (Reprinted with permission from Wagner, F.W., Jr.: The between the second and third, and between the fourth
diabetic foot and amputations of the foot. In DuVries' Surgery of the and fifth metatarsal shafts. The extensor tendons ov-
Foot, 4th Ed. Mann, R.A. (Ed.) St. Louis, The C . V. Mosby Co., erlie the shafts of the metatarsals and are used as
1978.) guides to their exposure. The necks of the metatarsals
are exposed extraperiosteally and the osteotomy is
Fig. 65. Closure over wick of lodoform gauze to allow escape of

hematoma from osteotomy site. (Reprinted with permission from
Wagner, F.W., Jr.: The diabetic foot and amputations of the foot. In
DuVries' Surgery of the Foot, 4th Ed. Mann. R.A. (Ed.) St. Louis,
The C. V. Mosby Co., 1978.)
ingrown nails. Pain had been severe enough to limit

ambulation. Both toes were operated at the same Fig. 66. Healed foot following resection of infected metatarsopha
time. The patient has had 5 trouble-free years of full langeal joint. Recent ulcer under second metatarsal head healec
school activity. with cast treatment.
made in each neck on a line that is 15' from the makes an excellent device to manipulate the head
transverse plane. The line of osteotomy should not while it is dissected free from surrounding soft tissue
describe an arc, as the most distal metatarsal end can (idea courtesy of Dr. Kelikian) (Fig. 69).
produce an ulcer due to concentrated pressure. A Final X-ray shows that the third metatarsal is a little
rocker-bottom shoe can relieve most of this pressure;
however, occasionally, additional bone will have to be
removed.
A Kritter drain is used for irrigation 24 hr postop-
eratively."7 The incision is closed by suturing skin and
subcutaneous tissues only. At 10 days, ambulation is
allowed with the foot in a short-leg walking cast. Extra-
depth or similar shoe style is prescribed when all
postoperative swelling is gone. A formed polyethylene
insert is used for protection of the plantar skin.
The patient in Figure 66 had an infected first meta-
tarsophalangeal joint following a plantar ulcer. Exci-
sion of all of the infected bone permitted healing. Over
the next year, the patient developed dislocation of the
second and third metatarsophalangeal joints with re-
sulting ulceration under the second metatarsal heads
(Fig. 67). The ulcer healed with casting. To prevent
further pressure problems, a Hoffman procedure was
planned.
Fig. 68. Transverse incision for metatarsal head resection. Lateral
A transverse incision was used for metatarsal head
edge of fifth metatarsal bevelled.
resection (Fig. 68). The tip of a Hagie pin with a handle
Fig. 67. X-ray of foot in Figure 66 with area of first metatarsopha-

lanyeal joint resected. Dislocated and deformed second and third Fig. 69. Hagie pin tip with handle to manipulate head during
rnetatarsophalangeal joints. removal (idea from Dr. Kelikian).
long. Fortunately, no problems have arisen (Fig. 70).

The patient is ambulatory in extra-depth shoes with a
Plastazote insole. No further ulceration has occurred.
Pain relief can be provided by removal of metatarsal
heads. Metatarsal pressure is evident in the feet in
Figure 71. The patient received minimal relief from
shoe inserts and medications. She was hypertensive
and diabetic with moderate peripheral neuropathy.
Following metatarsal head resection, she was pain
free. The soles of her feet in Figure 72 can be con-
trasted with those in Figure 71. There is no longer
intrinsic pressure at the metatarsal heads as evi-
denced by the looseness of the tissue where the
heads have been removed.
Transmetatarsal Amputation. McKittrick4' popular-
ized the transmetatarsal amputation in the diabetic
patient with his report in 1949; subsequent follow-ups
confirmed the value of the p r ~ c e d u r e . ~Use
' of the
Doppler ultrasound ischemic index has aided our se-
lection of patients for this procedure. Success rate in Fig. 71. Depressed metatarsal heads, claw toes Pain trom internal
as well as external pressures.
Fig. 72. Foot in Figure 71 following removal of metatarsal heads.

Pressure relief evident from looseness of skin under metatarsal
head area. No palpable pressure points remaining.
the literature averages around 65% with late failure

rate up to 15 to 20%. At Rancho Los Amigos Hospital,
primary healing now occurs in over 90%, and late
failures have been under 5%.
The indications would be: Gangrene of the toes and
Fig. 70. X-ray following removal of proximal phalanx of first toe forefoot, infection of the toes and forefoot not re-
and metatarsal heads 2, 3, 4, and 5. sponding to antibiotics, incision, and drainage, and
neurovascular foot problems with severe pain in the

toes and metatarsal areas. Doppler ischemic ratios
should be over 0.35 in the nondiabetic and over 0.45
in the diabetic. The patient should be ambulatory or
have such potential. The procedure is demonstrated
on a 68-year-old male with arteriosclerosis, hyperten-
sion, and alcoholic polyneuropathy. Pain in his toes
and metatarsal heads was unrelenting. He specifically
asked for the amputation. Doppler ischemic index was
over 0.50.
Technique. The dorsal skin incision is made at the
proposed line of bone division and is carried directly
to bone (Fig. 73). On the medial and lateral sides, the
incision comes to the midportion and then is directed
distally (Fig. 74). On the plantar surface, it traverses
the sole I-cm proximal to the web space. The meta-
tarsals are cut on an oblique line, angled 15' toward
the heel. The saw blade is slanted toward the heel as Incision carried to bone at all areas
Fig. 74.
the forefoot is pulled plantarward. This produces a
curved lower edge of the metatarsal shafts (Fig. 75).
We feel this is a major reason why so few pressure
areas have occurred in the postoperative period.
The distal foot is then sectioned from just under the
metatarsal shafts to the distal edge of the skin flap.
Hemostasis is secured with electrocoagulation and
fine absorbable ligatures. A Kritter drain is inserted
(Fig. 76). Closure is to the skin and subcutaneous
tissues only. A light compression dressing is applied.
The irrigation tube is removed at 24 to 48 hr. A non-
weightbearing case is used for 10 to 12 days and then
a weightbearing case for 6 weeks or until there is
good maturation of the tissues.
In roll-off or push-off, because of the loss of toes
and metatarsal heads, there is a concentration of
force at the ends of the metatarsal shafts (Fig. 77). A
Fig. 75. Flap formed by bevelling from under metatarsals to distal

skin edge Note inferior curve on all metatarsal shafts
flexible sole will increase that force significantly by

the length of the lever arm (Fig. 78). Pressure can be
reduced by stiffening the sole and rockering it, or by
fitting an orthotic device over the foot (Fig. 79). The
orthosis has a foam polyethylene toe block. Stiffness
is provided by the sides of the orthosis. It fits into a
regular shoe.
Lisfranc and Chopart Amputations. These levels
were developed before anesthesia, antibiotics, and
blood transfusions were available. The disarticulations
were relatively simple as no bone was cut and, after
severance of the joint capsules, the plantar flap was
Fig. 73. Outline of incision for elective transmetatarsal amputa- cut easily with two or three motions of the amputation
tion. Transverse portion at level of metatarsal necks. knife. The spread of infection seemed to be less with
Fig. 78. Augmentation of force by lever arm ot flexible sole. A

source of breakdown of plantar tissues.
Fig, 76. Incision closed with suture through skin and subcuta-
neous tissue only Kritter drain fluid exits between sutures May be
physiological or antibiotic solution
Fig. 79. Polypropylene orthosis used to protect a transmetatarsal

amputation. Stiffness provided by medial and lateral walls.
the cancellous bone spaces unopened. However, in

modern medicine, the need for speed is gone and
antibiotics aid in the suppression of infection. The
major problem that we have had a Rancho Los Arnigos
Hospital with these two levels has been plantar flexion
with resulting pressure areas. Dr. Richard Jacobs of
Albany, New York, has reported success with these
levels by adding tendo Achillis lengthening to the
operative procedure and a polypropylene ankle-foot
orthosis after the postoperative casting period. We
Fig. 77. Concentration of force at end of metatarsal and underly- have not had the Same Success at Rancho L O S Arnigos
ing soft tissue. Hospital, and pressures under the cuboid or calca-
neus have gradually led to ulcers that have required

a Syme’s amputation.
In elective and traumatic cases, it is possible to
transfer toe extensors and anterior tibia1 tendons to
the midline of the residual foot. They will effectively
balance the gastroc-soleus group so that equinus is
not a problem. In crush injuries, the distal face of the
residual foot is frequently covered with scar. In the
equinus position, this ulcerates rapidly. We have been
forced to convert such Lisfranc and Chopart amputa-
tions to Syme’s levels. Occasionally, a Boyd proce-
dure (fusion of calcaneus to tibia) has been done in
children.
The short transmetatarsal amputation is an opera-
tion similar to the Lisfranc. If soft tissue is not sufficient
to form a flap at the metatarsal neck area, or midshaft
area, the amputation can be done at the base. Retain-
ing the peroneus brevis at the base and scarring down
of the extensor tendons on the dorsum obviate some
of the problems of the Lisfranc level (Figs. 80 and 811.
Fig. 81. X-ray of amputation at base of metatarsals.
The shortened foot may not be able to hold on a shoe.
A high-top or a cuff sewn onto a regular shoe may be triply arthrodesis, and ankle arthrodesis can all be
necessary.
performed if the ischemic index is high enough.
Although some of the surgery described for the
Grade Zero foot is ablative, it is designed to relieve GRADE ONE FOOT
pressure and pain. Reconstructive surgery on this
type of foot almost always requires removal of some The algorithm for the Grade One Foot (Fig. 82) is
bone, whether for relief of pressure or to obtain rela- similar to that for the Grade Zero foot and is followed
tive soft tissue lengthening as in clawtoe repairs. in the same manner. Doppler evaluation is carried out.
Rarely will soft tissue procedures alone suffice. Stan- The patient is referred for possible revascularization
dard procedures for bunionectomy, clawtoe repair, if the ischemic index is under 0.35 for the nondiabetic
hammertoe repair, cavus foot, metatarsal osteotomy, and under 0.45 for the diabetic. Medical treatment
includes cultures, sensitivities, and appropriate anti-
biotic coverage.
Iodine has been useful in the treatment of open
lesions. No bacterial resistance has developed. A rare
patient has been allergic. Tincture of iodine is painful
and drying to tissues. Povidone iodine is rarely painful
and is compatible with raw surfaces. It is relatively
slow acting. Collens’ solution has been an excellent
agent in the treatment of infected wounds.” It is
compounded by dissolving 0.5 g of potassium iodide
and 0.5 g of crystalline iodine in 100 ml of distilled
water. A saturated solution is produced and a few
crystals remain undissolved. The penetrating power is
excellent and rapid. Collens‘o reports injecting the
solution into infected gangrenous tissue and achieving
asepsis. His article should be read for a description of
the mechanism of action. lodoform gauze is used as
a packing material in small wounds.
If the wound is less than 2 cm in diameter, it will
usually epithelialize rapidly. If the wound is extensive
as in a burn, it may be necessary to surgically debride
and skin graft.
Fig. 80. Short transmetatarsal amputation tor more proximal gan- Skin grafting was performed on a 52-year-old dia-
grene and infection. betic male with third-degree burns to both anterior
L - 2 - - 1-
Fig. 8 2 . Algorithm for Grade One foot with superficial ulcer
legs. The left ankle underwent autofusion secondary Fig. 83. Healed skin grafts following burn. Arthrofibrosis of left
ankle from burn, fixed in some dorsiflexion.
to burn arthrofibrosis (Fig. 83). Position of the ankle
in dorsiflexion due to positioning in bed. A great effort
the bony prominence results in rapid healing of the
was made not to permit equinus deformity. During
ulcer, frequently without skin grafting. Walking-cast
convalescence, walking casts were used to protect
treatment aids in healing of Grade Two lesions, both
the skin grafts from edema and to stabilize the ankle
in the pre- and postoperative periods.
joints. The patient is now ambulatory in polypropylene
The patient in Figure 86 developed this Grade Two
ankle-foot orthoses to prevent edema. Rocker-bottom
lesion beneath the naviculo-cuneiform joint secondary
shoes simulate ankle motion (Fig. 84).
to Charcot neuropathic breakdown. Walking-cast
Walking-cast treatment has aided in healing many
treatment aided in reducing edema and clearing up
small ulcers. If walking-cast treatment is unsuccessful,
the ulcer. Resection of bone was necessary for final
it may be necessary to debride and skin graft. In some
healing.
cases, it may be necessary to excise the ulcer and
For many lesions, the first treatment should be
enough of the underlying bone to obtain primary clo-
protection of some sort to see i f the body's own
sure. After healing of the wound, proper footwear is
healing mechanisms will be sufficient. The plantar
prescribed. The patient is continued on an education
ulcer in Figure 87 has been treated with a walking
program in care of his feet.
cast for 1 week. After an additional 2 weeks, the ulcer
GRADE TWO FOOT
is sealed over (Fig. 88). Another 2 weeks of casting
produces further healing. Protective shoes are pre-
The Grade Two lesion (Fig. 85) is deeper than the scribed. If the ulcer recurs, the metatarsal shaft is
Grade One lesion and penetrates to bone, joint, cap- osteotomized or the head removed.
sule, tendon, or ligament. Treatment parallels that of The lesion in Figure 89 is similar to that in Figure
the Grade One lesion. Because of the depth of the 86. Walking-cast treatment has cleared up the ulcer
wound, larger areas do not epithelialize well. Debride- but the underlying bone is still present. The excess
ment and skin grafting are more often necessary. bone under the naviculo-cuneiform joint was removed
Residual internal pressures from bony prominences surgically (Fig. 90). One month of postoperative walk-
frequently keep the ulcer open (Fig. 86). Removal of ing-cast treatment has produced marked reduction of
Foot & Ankle/Vol. 2. No. 2 THE DYSVASCULAR F 0 3 T 99
-~-_-L-
NFCESSAHY
SdIN GRAFT AS
~
NECESSARY
I- &,-.---
< -
'TI---_
Fig. 84. Ankle-foot orthosis of polypropylene with anterior tongue Fig. 85. Algorithm for Grade Two foot, ulcer to tendon. ligament,
for edema control. Extra-depth shoe with thickened sole and rocker bone, and joint
bottom to simulate ankle motion and to adapt for dorsiflexed position
of foot.
those obtained at surgery from the depth of the
wound. The determination of the true pathogen is
the ulcer and surrounding swelling (Fig. 91). Contin-
difficult. At times, gas shadows on the X-ray and
ued protection in a polypropylene ankle-foot orthosis
crepitation on palpation may suggest clostridal gas
has prevented further bony deformity and allowed full
g a n g ~ e n e .57
~ . Cultures have rarely been positive for
healing of the ulcer (Fig. 92). The patient will continue
clostridia. Operative debridement is mandatory, but
to receive care for protection of both feet and will
the greatest number of cases will be spared a major
receive reinforcement of previous instruction in home
amputation.
care of the feet.
A broad spectrum antibiotic frequently will aid in
GRADE THREE FOOT defervescence and reduction of surrounding cellulitis.
However, the most often used antibiotic combination
Algorithm for Grade Three foot with deep abscess includes an aminoglycoside and a semi-synthetic pen-
or osteomyelitis, Figure 93. This grade of foot lesion icillin. These are prescribed after sensitivities have
presents some of the more difficult problems in deci- been determined. Monitoring of serum peak-and-
sion-making and care. The foot is again analyzed for trough levels and obtaining of creatinine levels have
vascular dysfunction by Doppler ultrasound. The pa- aided in the prevention of ototoxicity and nephrotox-
tients with decreased ischemic indexes are evaluated icity.
for revascularization procedures. Medical treatment Surgical removal of infected tissues is one of the
includes vigorous control of the underlying diseases. most effective treatments. Timing of the surgery is
Antibiotic treatment is guided by cultures and sensitiv- sometimes difficult. On occasion, a fluctuant abscess
ities. A mixed flora is almost always present with both must be drained as a semi-emergency procedure.
aerobes and anaerobes 5' We have found After intravenous antibiotics have been started, the
it virtually impossible to sterilize such wounds with temperature and white blood count are monitored.
antibiotic treatment only. There is also little correlation When the temperature curve shows a downward trend
between cultures obtained from surface drainage and and the white blood count has dropped below
Fig. 86. Grade Two lesion under naviculo-cuneiform ioint.
10,00O/ml, the surgical success rate has been the

h i g h e ~ t . ’If~ the temperature stays up or increases Fig. 87. Grade Two lesion under depressed metatarsal head.
and the white blood count does not go down, an Began as callus. Has had 1 week of walking-cast treatment.
amputation or wide surgical debridement is performed
as a semi-emergency procedure. The amputation level The Shirley drain is a two-lumen tube based on the
is determined by the ischemic index. On occasion, older Chaffin sump drain for abdominal wounds. To
deoridement may be possible at the infected level prevent the intestines and other soft tissues from
when the ischemic index is high enough. being sucked against the drain, air was introduced
In the Grade Three foot, there is almost always more into the abdominal cavity through a separate perfo-
deep infection than appears from the external signs rated tube. The Shirley drain accomplishes this same
of heat, redness, and swelling. Ray and midfoot am- action through two lumens, one for air and one for
putations require careful dissection to make sure that suction. This drain is modified for irrigation and drain-
no diseased or necrotic tissue is left behind. If the age by taking the filter from the air tube and attaching
infecting dose from the diseased tissue is reduced to an intravenous tubing system. The drain is brought
virtually zero by its removal, the residual foot can into the wound through a separate stab incision. Fluid
handle the remaining infection with the aid of irrigation is fed into the wound at 1000 m1/24 hr. The exit tube
and antibiotics. The dysvascular foot cannot rid itself is not connected to suction but to gravity drainage.
of devitalized and infected tissue by ordinary incision The outflow tube is clamped for 5 min every 2 to 3 hr.
and drainage methods; conservative debriding can This distends the wound and allows better dilution of
save a hematoma and washing out of debris, including bac-
Wound irrigation and drainage are provided by two teria. The system is left in place for 48 to 72 hr. If the
systems. If the cavity is larger, as in a Syme’s or effluent become cloudy, cultures can be taken. Tubes
Chopart amputation, the modified Shirley drain is used have been left in successfully for up to 2 weeks. This
(Fig. 42). If the wound has virtually no cavity, as in a system has been used for more than 11 years without
transmetatarsal or toe and ray resection, the Kritter complication.
drain is used3’ (Figs. 39 and 76). Kritter has devised a system for irrigating smaller,
Fig. 88. Grade Two lesion after additional 2 weeks in walking Fig. 89. Grade Two ulcer under cuneiform area. Bony prominence
cast. Note eschar over ulcer. Protective shoe insert used after from Charcot breakdown.
lesion healed.
closed wounds following partial amputations and de-

bridernent~.~' It has been used in hundreds of cases
at Rancho Los Amigos Hospital with marked success.
The tube is brought into the wound through a separate
stab incision. Wounds are closed with sutures through
the skin and subcutaneous tissues only. Irrigating fluid
exits between sutures (Figs. 39 and 76). The major
functions are to dilute hematoma and bacteria, and
wash out debris. We have used an infant feeding tube
with extra holes cut into the last 2 to 5 cm. It is kept
in place for 24 to 48 hr. Originally, a 0.1 YO Neomycin
solution was used as the irrigant. The useful role of
surface antibiotics is debatable and Ringer's lactate
or similar solution is used now.
A partial foot resulting from resection of infected
tissue is quite serviceable. Virtually any combination
of toes and rays can provide a walkable foot. Special
inserts and sole stiffeners provide stability as neces-
sary. Removal of toes 4 and 5 and oblique resection
of metatarsals 4 and 5 has left virtually no residual Fig. 90. Grade Two lesion after excision of bony prominence
disability in this patient (fig. 94). through separate incision above the ulcer.
MEDICAL THEATMFNT
ci OSE OVFr
KHITTEP DRAIN IF
Fig. 91. Grade Two lesion after 1 month of walking cast. Note dry
eschar over whole ulcer. Patient independent in walking cast.
Fig. 93. Algorithm for Grade Three foot-deep abscess or osteo-

myelitis.
Fig. 92. Grade Two ulcer after excision of bone, walking-cast

treatment, and 2 months of protection in ankle-foot orthosis. Ante-
rior tongue added for edema control. Ulcer had epithelialized with-
out skin graftifig or other closure.
A functional foot remains after removal of all lesser

toes and oblique resection of metatarsals 2, 3, and 4,
and complete removal of the fifth metatarsal (Fig. 95).
The patient had several attempts to incise and drain
lateral abscesses that started from a callus under the
fifth metatarsal head. He is 79-years old and has a
below the knee amputation on the right. He did not
have the cardiac reserve to walk with bilateral
prostheses. The partial foot has kept him ambulatory.
Residual lateral claw toes produced enough deform- Fig. 94. Partial foot resulting from excision of infected tissues of
ity that severe calluses resulted in infection of the toes four and five and metatarsals four and five
function was excellent. Both feet have continued func-

tional.
Walking-Cast Treatment
One of the nonoperative treatment methods men-

tioned in each of the Grades so far is the walking cast.
Plaster of Paris splints and circular dressings for
wounds are not new. They were used in World War I
for protection of amputation stumps during transpor-
Fig. 95. Partial foot resulting from excision of a\\ lateral toes,
oblique excision of metatarsals 2, 3, and 4, and complete excision
of metatarsal 5.
lateral toes, A transmetatarsal amputation of rays 2,

3, 4, and 5 was performed 1 year after the first
metatarsal head and toe were removed for an infected
ulcer. A completely serviceable foot has resulted (Fig.
96). Elective surgery is not usually indicated at the
same time that infected tissue is being removed. The
residual clawtoes broke down before prophylactic sur-
gery could be performed, despite what was consid- Fig. 96. Partial foot resulting from removal of first toe and meta-
ered adequate shoe protection. tarsal head at first operation. Transmetatarsal amputation of 2, 3,
This 68-year-old woman (Figs. 97 and 98) was 4, and 5 at second operation 1 year later.
admitted with infected ulcers of her second and third
toes with extension into the metatarsal head area.
There was cellulitis dorsally on the foot. Several days
of intravenous antibiotics defervesced the patient and
quieted the cellulitis. She then requested the ampu-
tation pictured on the left foot. Eighteen months pre-
viously, on the right side, she had had three attempts
at incision and drainage of similar ulcers and ab-
scesses at an outside hospital before the amputation
was performed on the right foot at Rancho Los Amigos
Hospital. The right foot was then so serviceable that
she had no qualms about a similar procedure on the
left. In surgery involved tissues were easy to identify
by decreased vascularity, presence of pus, punctate
hemorrhages, avascularity of fascia1 tissues, and dis-
coloration of tendons in the affected areas. Unfortu-
Fig. 97. Plantar view of left foot following removal of toes 2, 3, 4,
nately, black and white photographs do no justice to and 5 ; and metatarsals 2, 3,4,and 5 obliquely for infected toes in
these sometimes subtle changes. At 10 days following metatarsal area. Right foot operated 18 months previously. Both
surgery, she was placed in a walking cast. Ambulatory feet functional.
nonwalking basis for 10 to 14 days, and then finally in

full walking.
The total contact walking cast has thus been an
invaluable aid in the treatment of foot, ankle, and
lower leg problems, as well as postoperative amputa-
tion care of the neurovascular patient. The cast is
applied after grading of the lesion and Doppler eval-
uation of circulation. It has many specific actions:
1. Mobilization of the patient. Neurovascular pa-
tients do poorly with prolonged bed rest. Both younger
and older meningomyelocele patients with foot lesions
develop demineralization of bone, kidney stones, and
general body atrophy if kept in bed too long. Elderly
arteriosclerotic and diabetic patients, in addition to
the above, go into negative nitrogen balance, develop
pressure ulcers at bony prominences, and can require
prolonged rehabilitation after bed rest. With the cast
on, the patient has virtually the same ambulatory
status as before the foot problem.
2. lmmobilization of the part. Lesions in the area of
joint motion heal much more rapidly when the joint is
kept motionless. If toe motion is desired, the cast can
be stopped just proximal to the metatarsal heads. If
there are open lesions, the cast generally covers the
toes.
3. Distribution of pressure. A lesion under a meta-
tarsal head or other bony prominence will heal with
Fig. 98. Dorsal view of feet in Figure 97. The patient has an
excellent gait. Regular shoes are used with a foamed polyethylene amazing rapidity when the metatarsophalangeal joints
filler. and ankle joints are immobilized. The pressure is
spread to other areas of the foot, sparing the ulcer.
tation from front-line emergency hospitals to hospitals The cast must be applied in slight dorsiflexion or with
at the rear or to hospitals in the patient’s homeland. a walking heel so that a heel-to-toe gait is possible.
Wounds so treated arrived in much better condition 4. Control of edema. The cast evidently aids in the
than those transported while covered with soft dress- return of lymph as well as venous blood. When a cast
ings. is applied on an edematous leg and foot, swelling may
During the 1920s, an occasional article reported decrease so rapidly that the cast must be changed
success in treating foot ulcers of leprosy with walking within a day or so because of looseness. After the
casts. Later experience from India and from the United extremity has reached a “dry weight,” the effect is
States, reported by Paul Brand, F.R.C.S., confirmed frequently long-lasting. I have a series of patients
the value of walking casts in leprous ulcers. Marian whose ischemic index has improved following pro-
Weisz of Poland reported muscle stabilization, cast longed casting. The effect is continued by the wearing
protection, and immediate ambulation for lower ex- of a polypropylene ankle-foot orthosis with an anterior
tremity amputations in the 1960s. A wave of enthusi- tongue. This has been an excellent edema control
asm swept around the world for the use of immediate device to supplement the walking cast.
cast ambulation. A study at Los Angeles County/ 5. Support of Charcot joints. Acute breakdown of
University of Southern California Medical Center re- Charcot arthropathy should be immobilized immedi-
ported a large series of amputees with soft dressings, ately. As healing progresses, weightbearing is begun.
plaster dressings, and plaster dressings with pylon Chronic deformities are then treated with an orthosis,
and immediate ambulation. It was found that soft surgical stabilization of joints, or surgical removal of
dressings produced the lowest rate of healing. Plaster bony prominences. Continued support is provided
dressings with and without ambulation were superior. with the polypropylene ankle-foot orthosis as neces-
lmmeddiate ambulation prolonged the healing time sary.
and did produce some wound breakdown that finally 6. Postoperative support of surgical wounds. Most
healed with prolonged casting. Based on these find- foot procedures are irrigated through Kritter tubes or
ings, plaster has been used postoperatively, first on a irrigated and drained through modified Shirley sump
drains. After these tubes have been removed, the foot

is allowed to dry out for 1 or 2 days. Nonwalking casts
are applied for 10 to 14 days. After this time, ambu-
lation is allowed with crutches or walker assistance
until the patient is independent. The cast is continued
for about 6 weeks until good maturation of the wound
has occurred.
7. Postoperative maturation of wounds. Diabetic
and other dysvascular wounds take a longer period to
achieve full healing. Continuation of edema, discolor-
ation of wound edges, palpable increase of local tem-
perature, tenderness, and similar findings show the
need to continue protection for much longer than in a
normal patient. In some cases, the ankle-foot orthosis
is substituted for the cast if it appears that support will
be required for more than 8 weeks.
The following case is illustrative of the use of the
total contact cast in a patient not suitable for a revas-
cularization procedure and with an ischemic index too
low for predictable healing of local ulcers or local
Fig. 100. The superficial and deep femoral arteries are both open
surgery at the foot level. but diseased portions are present in all areas visualized.
A 65-year-old Caucasian male with diabetes melli-
tus for 9 years was seen for early gangrenous changes
in the left fourth toe and an adjacent ulcer in the third
toe. The abdominal aortogram with run-off showed
diffuse atherosclerotic changes of the abdominal aorta
(Fig. 99), degenerative changes in both superficial
and deep femoral arteries (Figs. 100 and 1011, and
advanced disease of both trifurcations (Fig. 102).
There was no “run-off’’ in the leg below the trifurcation
(Fig. 103). The ischemic index was 0.36 at foot and
Fig. 101. The popliteal arteries are open but with stenosis.
ankle and 0.56 at the knee. The patient was placed in

a short-leg walking cast. Casts were changed at 2-
week intervals and the toes debrided as necessary.
After 2 months, healing was sufficient that casts were
left on for a period of a month. After two further casts,
the foot was warm, all lesions had healed, and there
was no pain. Extra-depth shoes with foam plastic
inserts were ordered. The ischemic index was 0.5 at
Fig. 99. Abdominal and pelvic portion of angiogram. Some ste-
nosis of left common iliac artery is noted. Scattered areas of
the ankle and midfoot.
stenosis but with good collateralization around the common femoral One year later, the patient developed multiple small
arteries. gangrenous areas over the right foot on both sides of
Casting and debriding were done at weekly inter-

vals. By 2 months, all of the smaller areas had healed.
Bleeding had increased at the large ulcer over the first
metatarsal. Granulation tissue had begun to form.
During this period, the patient continued to work as
manager of a metal plating shop. By 3 months, the
Doppler index had increased to 0.46 just below the
ankle. The ulcer at the bunion area had exposed
devitalized bone in the center and it was apparent that
sufficient granulation tissue could not form to cover
the bone. In addition, X-ray examination showed os-
teomyelitis of the proximal phalanx of the great toe
(Fig. 104). The patient was admitted to the hospital
for surgical removal of infected tissues. The first,
second, and third toes, the first and second metatar-
sals, and the first cuneiform were excised. All devital-
ized and infected tissues were removed. The wound
was closed over a Kritter irrigation tube. At 1 week,
the Kritter drain was removed and a nonwalking cast
applied. At 2 weeks, a walking cast was applied and
Fig. 102. Full occlusion at the trifurcation with some filling of the
peroneal arteries by collateral flow. the patient was discharged. At 3 weeks, the distal
wound opened. The patient then underwent a Syme's
amputation. The walking-cast treatment had raised
the ischemic index enough to permit an ankle-level
amputation. During surgery, the post-tourniquet
bleeding test showed return of flow to the most distal
flap at exactly 3 min.
The patient, thus, has two Grade Zero feet-the left
one with minor tissue loss at the third and fourth toes,
and the right with partial foot at the Syme's level.
Post-tourniquet Bleeding Test
During past surgical procedures for the Syme's

amputation, the patients' vascular function had been
continuously observed. It was noticed that, after the
infected or gangrenous foot was removed in cases
done without a tourniquet, bleeding in the heel pad
began to increase markedly during the 5 to 1 0 min
interval after removal of the foot. Similar observations
have been made following removal of crushed or
diseased segments of arteries in the upper extremi-
ties. The remaining vessels lose spasticity after the
Fig. 103. Virtually no flow below the trifurcation, indicating no involved segments have been resected.
vessels to accept a graft. With use of the pneumatic tourniquet, it has been
observed that bleeding does not always begin imme-
the heel, tip of the great toe, base of the fifth metatar- diately after release in patients with arteriosclerosis.
sal, and also a large ulcer over the bunion area ex- Timing of return of bleeding to the distal-most skin in
tending to the midshaft of the metatarsal. a Syme's heel flap provided some numerical rating of
Doppler evaluation showed poor vascular sounds, the degree of circulation available. This also obviously
poor collateralization, and an index of 0.38 at the indicated some of its healing potential. Healing of 80%
ankle, and 0.27 at the toes. Short-leg walking casts of cases was obtained when the distal-most skin bled
were started with Povidone iodine gel packs to the by 3 min. Healing was below 70% when returning
open areas. Based on his previous angiograms, he bleeding was over 5 min. In the case just described,
was not a candidate for revascularization procedures. the ischemic index was 0.46 and the post-tourniquet
GRADE FOUR FOOT
Algorithm for Grade Four foot, gangrene of toe,

toes, or forefoot (Fig. 105). Since there is gangrene
of some portion of the toes or forefoot, there will
ultimately be some tissue loss. A partial foot always
results unless higher amputation is necessary. As in
other grades, the vascularity is assessed by Doppler
ultrasound and revascularization planned as neces-
sary. Medical treatment is similar to that of Grade
Three. Gangrene of toe tips and even of whole toes
may be treated expectantly with resulting auto-am-
putations (Fig. 106). The major danger in waiting for
this to occur is the development of wet or infected
gangrene. We have rongeured devitalized tissue to
within a few millimeters of viable tissue (Fig. 107). It
is usually necessary to remove bone proximal to the
edge of the viable soft tissue so that the skin can close
over the end of the bone. Natural healing produces a
remarkably cosmetic tip in most instances.
Amputation of Toes
Fig. 104. Remarkably good mineralization of bone. This is felt to Gangrene, soft tissue infection not responding to
b e related to walking-cast treatment. Lytic lesion of proximal pha- treatment, and osteomyelitis may necessitate ampu-
lanx of great toe is probably osteomyelitis. tation of a toe. Any toe or all of the toes may be
removed with relatively little loss of function. Loss of
bleeding time was exactly 3 min. The Doppler index the great toe may lead to awkward push-off in hurried
has now largely supplanted the post-tourniquet timing or forceful gait. This can be corrected readily with
as it can be obtained preoperatively and allows better stiffening and rockering of the sole of the shoe.
surgical planning. Level selection is determined first by Doppler is-
Use of Tourniquet During Surgery
chemic index and then by clinical consideration such
as presence of pus, length of flap available, and
Statements such as "never use a tourniquet on a residual function possible. Removal of all of the lateral
dysvascular amputation" are common in articles on toes, with or without portions of the metatarsals,
lower extremity amputation. Equal numbers of cases leaves a very functional foot. (figs. 61, 95, 97, and
at each level (25-30) were operated, one-half with 98)
and one-half without tourniquet at foot, ankle, calf, or Surgical Technique. The toes may be amputated
knee levels. Complications relating to nonhealing all through any of the phalanges or disarticulated through
appeared the same, i.e., breakdown of wound edge, any of the joints. The flaps should be long enough to
continuation of infection, or progression of previous close without tension. They may be of any shape, fish
thrombosis. However, there was noted to be a 50% mouth, side-to-side, long dorsal flap, long plantar flap,
increase of postoperative complications in the above or similar. To insure adequate circulation to the flap,
the knee group of amputations. For this reason, the the length should not be over 50% greater than the
tourniquet is not used on any thigh amputation except width at the base. Before any flap is sutured, it should
in young patients amputated for trauma, tumor, or be tested by manual closure and palpation to be sure
congenital deformity. It is postulated that the tissue it will close without tension and to be sure that no
and circulation remaining below the tourniquet are not bony prominence is present to cause a later pressure
able to handle the metabolic changes and tissue problem. Angular edges are rounded and excess bone
trauma resulting from even short use of the tourniquet. removed as necessary. Figure 108 demonstrates an
In lower amputations, the basic rule is to release the incision for removal of the great toe for osteomyelitis
tourniquet the instant the affected part is removed. In of the proximal phalanx and infection of dorsal skin.
most cases, the tourniquet is inflated for not longer A long plantar flap was formed to cover the area of
than 20 min. dorsal skin loss.
EVALUATION
NO 0 {y]MELLITUS
YES EVALUATION
INDEX OVER
YES
MEDICAL TREATMENT
VIGOROUS CONTROL OF UNDERLYING
DISEASE X-RAY CULTURES SENSITIVITIES,
I V ANTIBIOTICS: LOCAL 1 ' 8D OF
TEMPERATURE
DECREASING
SURGICAL DEBRIDEMENT AT LEVEL
INDICATED BY DOPPLER
AMPUTATION AT FIRST ELECTIVE
LEVEL ABOVE INFECTION
OPEN AMPUTATION AT LEVEL OF
INFECTION IRARELY)
TOE & RAY RESECTION

AMPUTATION
WALKING CAST
HEALING SHOE
SHOE CORRECTIONS
SECOND
c-,
PROSTHESIS
Fig. 105. Algorithm for Grade Four foot. Gangrene of toe, toes, or forefoot
Toe and Ray Resection to the web space so that enough skin is available for
closure. The ulcer or gangrene is outlined at its prox-
If the infection or gangrene has spread into the
imal end and the metatarsal shaft is excised extraper-
forefoot, it is sometimes necessary to remove a rneta-
iosteally. Subperiosteal dissection not infrequently
tarsal head or head and ray to gain enough skin and
leads to postoperative bone formation. Hemostasis is
soft tissue to close the wound. All combinations have
secured with fine ligatures and pinpoint electrocoag-
been performed and found to be successful. The
uation. The flaps are tested by manual closure. Bone
residual foot is functional in the highest percentage of
may have to be removed to gain flap length. Removal
cases. The basic principles that we have followed are:
of the adjacent toe and its metatarsal head is some-
times necessary to gain sufficient flap length. Closure
1. All infected tissue must be excised. is over a wick, a suction drain, or a Kritter irrigation
2. Flaps must be closed without tension. tube.
3. All cavities must be irrigated and drained, The patient in Figure 109 developed a lesion over
drained with a Hemovac, or drained with a wick. the proximal interphalangeal joint of the fifth toe. This
4. Bony prominences should be removed. progressed to a blister and infection at the metatar-
5. Cultures are taken just before closure and sen- sophalangeal joint. Treatment in a walking cast con-
sitivities are determined to aid in antibiotic selection. verted the lesion to dry gangrene. In surgery, a flap
Technique. The incision on the toes should be distal was developed in one layer down to bone (Fig. 110).
foot & Ankle/Vo/. 2, No. 2 THE DYSVASCULAR FOOT 109
Fig. 108. A long plantar flap from the great toe is used to cover
the dorsal defect which results from removal of the great toe and
adjoining infected skin.
Fig. 106. Dry gangrene of tip of the third toe.
Fig. 109. Dry gangrene of the fifth toe and tissues over the head
of the fifth metatarsal. This foot has been treated with a walking
cast. The original lesion was a blister over the fifth PIP joint.
If the dorsal skin is involved proximal to such a

Fig. 107. Local debridement removes gangrenous tissue just dis-
lesion and the metatarsals are not involved at the
tal to the level of bleeding. base, the skin can be debrided and the defects cov-
ered with a split thickness skin graft (Fig. 113 ) . Plantar
The fifth toe, fifth metatarsal, and the head of the skin grafts rarely do well except in areas which are
fourth metatarsal were removed. The wound was completely weight free. Dorsal skin grafts wear well
closed over a Povidone iodine-soaked wick (a Kritter and rarely suffer later breakdown (Fig. 114).
drain is now used) (Fig. 11 1). At 3 months following Transmetatarsal, Lisfranc, and Chopart amputa-
surgery, the foot is serviceable (Fig. 1 12). tions are performed for the Grade Four foot much as
110 WAGNER Foot & Ankle/Vol 2 , No. 2
The Syme’s Amputation
James Syme first reported amputation at the ankle

in 1843.6‘Then, as now, it was a controversial pro-
cedure. Continental European surgeons appeared to
have had trouble with excision of the 0s calcis. Piro-
goff and others devised methods to leave the posterior
inferior portion of the 0s calcis to be arthrodesed to
the distal tibia. This has the disadvantage of possible
painful nonunion and of leaving a bony prominence
that can cause later ulceration. Early limb fitters and
prosthetists disliked the bulbous end and persuaded
surgeons to narrow the end of the tibia by a more
proximal division of the bone. This decreased the
weightbearing surface and negated much of the func-
Fig. 110. The skin flaps are developed in one layer down to bone.
The towel clip is in the fifth metatarsal. The head of the fourth
metatarsal is at the distal end of the wound.
Fig. 111. Povidone iodine-soaked wick is used for drainage of the

wound. It is removed at 48 hr.
Fig. 113. Resection of toes and metatarsals 3, 4, and 5 for
infected gangrene. Dorsal skin lesion was excised and covered with
split thickness skin graft.
Fig. 112. The wounds have all healed and a serviceable foot
remains. There are no residual pressure areas.
for the Grade Three foot. Doppler ultrasound has

provided the highest correlation with preoperative se-
lection of site of surgery and postoperative healing. lf Fig. 114. Residual foot after resection of rays 3, 4, and 5, and
more distal resections are not possible, the Syme’s or dorsal skin graft. The residual areas of callus under the third and
ankle level has proven highly successful. fourth metatarsal heads are still visible.
tional value of the stump. To emphasize Syme’s orig-

inal concepts, R. I. Harris of Toronto has written two
erudite articles on the Syme’s amputation and they 12
remain classics.23.24 I1
10
There are few articles on the use of this amputation
0.9
in the dysvascular patient.”, 49. 52. 58 Its use in young,
healthy patients appears to be well accepted. In 1954,
Spittler and associates reported Korean War experi-
‘
cr,
k!
0.8
07
0.6
ence with a two-stage procedure devised by $ 0.5

04
H u l n i ~ k Forefoot
.~~ wounds from land mine injuries
03
and from sharpened sticks smeared with human ex- 02
crement were not amenable to forefoot amputations. 01
There was a high failure rate of the Syme’s procedure
due to continued infection. Because the Syme’s level N SYM. B/K A/K
is so functional, attempts were made to keep this Fig. 115. Stride length in meters measured in dysvascular ampu-
amputation for those patients. A disarticulation was tees. The Syme’s level is slightly longer than for other amputees.
Note increased stride length of above the knee amputee on crutches
performed and allowed to heal. The definitive Syme’s
with the prosthesis off.
amputation was performed 6 to 8 weeks later when
healing of the first stage was secured. With this two-
stage technique, virtually 100% healing was obtained.
I performed the two-stage procedure at Los Angeles
County Hospital in 1954 and have been using it since 96
then in cases of dysvascular, diabetes mellitus, trau- 84
matic loss, congenital and acquired deformities, and
72
neurological dysfunction. In my private practice, at ?
Rancho Los Amigos Hospital, and at Los Angeles $ 6o
County/University of Southern California Medical 2 48
Center, the combined experience is now over 550 & 36
cases. The early success rate was 50%. Addition of * 24
the two-stage method increased this to 70%. Timing 12
the post-tourniquet return of circulation raised the rate 4
to 80%. In this method of estimating circulation, the N SYM B/K A/K

tourniquet is released as soon as the foot has been Fig. 116. Cadence in steps per minute. Lower levels of amputation
(j
separated. The appearance of bleeding in the distal- allow a more rapid gait.
most skin is timed. If it is not returned at 5 min,
amputation is seriously considered at the next proxi-
mal level.
Addition of the ischemic index obtained with the GAIT VELOCITY
Doppler ultrasound flowmeter has raised the total
success rate to over 90%. When several recent con-
secutive series of 50 patients were assessed, the rate
was 87 to 96%. Patient acceptance of the Syme’s cn
[L 30
amputation has been excellent. They rate a loss at the
ankle as an annoyance, but the loss at the below the
knee level a disability.
w
Gait studies in the Pathokinesiology Laboratory at
Rancho Los Amigos Hospital, under the direction of
= 20
Dr. Jacqueline Perry, have consistently shown the 10

Syme’s level to be superior to other major lower
extremity levels.69 Dysvascular amputees have been AK BK
tested at the Syme’s, below the knee, and above the VASCULAR TRAUMATIC
AMPUTEES AMPUTEES
knee levels.69In stride length (Fig. 1 1 51, cadence (Fig.
Fig. 117. Velocity in meters per rnin. The performance of the
1161, and velocity (Fig. 1171, the Syme’s amputees
Syme’s amputee is superior to other levels in the dysvascular
are superior. In the final test of efficiency, oxygen patients. Contrast of performance between above the knee and
consumption, the Syme’s amputee uses less oxygen below the knee younger traumatic amputees shows the value of
3er kilogram per meter of travel than either below the saving the knee if at all possible.
knee or above the knee levels (Fig. 118). Of added

interest are the markedly higher oxygen consumption
in above the knee amputees (save the knee if at all
possible), and the greater stride length in the above
the knee amputee with his prosthesis off and using
crutches for propulsion. When clinic and prosthetic
return visits are analyzed, Syme's amputees have
fewer skin problems, fewer returns for stump ulcers,
less prosthetic breakage, and require less mainte-
nance of their prostheses.
Indications. The Syme's amputation is indicated in
cases of foot infection and gangrene not responding
to treatment and not suitable for a more distal ampu-
tation. The major determinant is the ischemic index. If
the index is above 0.45 in the diabetic and above 0.35
in the nondiabetic, the decision is then made on
clinical criteria. The patient must be a potential pros- Fig. 119. Syme's amputation. Outline of incision is 1 cm below
thetic user. The skin of the heel flap must be intact and 1 cm anterior to the tip of the lateral malleolus.
and the fat pad should not be grossly infected.
Surgical Technique. The two-stage method is used
for cases in which the forefoot is grossly
infected.56 64-68 The single stage is used for dry gan-
grene, chronic ulceration without gross pus, and acute
loss of vascularity from trauma. Except for the level of
incision and removal of distal tibia in the single stage,
the methods are identical.
Two-stage. The incision starts 1 to 1.5 cm distal
and 1 to 1.5 cm anterior to the tips of the malleoli (Fig.
119 and 120). This produces a slightly longer flap
that will then cover the malleoli without tension. The
incision goes to bone without dissecting any tissue
planes. On the dorsum, the tendons are exposed,
pulled down, divided, and allowed to retract (Fig. 120).
The vessels are divided and ligated.
The collateral ligaments are cut from side-to-side,
OXYGEN CONSUMED
PER METER TRAVELED
35 Fig. 120. Syme's amputation. The tendons are pulled down, di-
vided, and allowed to retract. No tissue planes are developed.
allowing the talus to dislocate from the mortise (Fig.

121). There is no fixed sequence for this division
except that the tightest structures are cut each time.
Care must be taken not to divide the posterior tibia1
nerve and artery as they pass just inside and inferior
= 10 to the medial malleolus. The exposure of the posterior
0s calcis is begun laterally. As the dissection is con-
05
tinued medially, the tendon of the flexor hallucis lon-
gus is encountered (Fig. 122). This marks the outer
VASCULAR TRAUMATIC border of the neurovascular bundle and can be used
AMPUTEES AMPUTEES to protect the nerve and artery in further dissection.
Fig. 118. Oxygen consumed per meter traveled. The amputee The 0s calcis is exposed subperiosteally except at the
requires extra energy consumption for ambulation. The Syme's insertion of the tendo Achillis and the plantar aponeu-
level is superior to other levels in the dysvascular patient. The lesser
performance of above the knee amputees in both dysvascular and rosis (Fig. 123). At these points, the Sharpey's fibers
traumatic amputees confirms the value of saving the knee. are cut with a scalpel because of their toughness.
skin by 5 min, consideration should be given to con-

tinuing the amputation at the next highest level. He-
mostasis is completed with absorbable sutures to the
deep vessels and pinpoint electrocoagulation to the
minor ones. Minor bits of debris are manually removed
from the pad. The flap is tested to check for tension
(Fig. 124). If the malleoli are too prominent, small slits
can be made in the fat of the heel pad to nest the
malleoli. If the flap is too long, it can be shortened. A
Fig. 121. Syme's amputation. The deltoid ligament is divided

under direct vision. Care is taken not to divide the posterior tibia1
nerve and artery just beyond the tip of the scalpel blade.
Fig. 123. Syme's amputation. Subperiosteal dissection of the 0s

calcis protects the fibrous septa of the heel pad. The hook is in the
dome of the talus and aids in control of the foot during dissection.
Fig. 122. Syme's amputation. The flexor hallucis longus tendon is

at the tip of the clamp. It marks the lateral edge of the neurovascular
structures. Dissection carried out laterally is safe.
There is always a ridge at the posterior-inferior edge

of the retrocalcaneal bursa. In directing the scalpel
blade posteriorly to avoid this ridge, it may slip and
penetrate the skin. This can be avoided by small,
careful changes in direction. Final stripping of the 0s
calcis will complete the removal of the foot. The tour-
niquet is released and timing is begun. This procedure
rarely has taken more than 15 to 20 min up to this Fig. 124. Syme's amputation. Manual testing of closure allows
period. If bleeding has not returned to the distal-most revision as necessary before sutures are placed.
Shirley drain is brought into the cavity through a compression dressing of fluff gauze and stockinette is
separate stab incision (Fig. 125). The wound is irri- applied.
gated with fluid brought in through the air tube of the Postoperative Treatment. Irrigation is continued for
Shirley drain. The fluid exits through the perforated 48 to 72 hr. When the drain is removed, the tip is cut
tube to a gravity drainage bag. The irrigating fluid may off aseptically and sent to the laboratory for cultures
be normal saline, Ringer's lactate, 01' similar physio- and sensitivities. Antibiotics are continued for 1 0 days
logical solution, and with or without antibiotics, ac- and are changed if a different organism is found or if
cording to the surgeon's preference. The deep fascia the sensitivities have changed.
of the heel flap is sutured to the periosteum of the At 10 days, a walking cast is applied (Figs. 127 and
anterior tibia and to the ligamentous tags remaining 128). If the medical condition permits, the patient is
on the malleoli. The subcutaneous fat is closed with then discharged, to be followed as an outpatient.
horizontal sutures so that the skin edges are leveled. Casts are changed as swelling decreases. The sutures
The skin is closed with nonabsorbable sutures (Fig. are removed at 4 weeks. In the one-stage procedure,
126). The dog ears are not trimmed or tidied. A the patient is ready for a prosthesis at 8 to 1 2 weeks.
Second Stage. The first stage has been a disarti-
culation to remove the open, draining forefoot. When
the infected forefoot is removed, the residual limb and
body appear to be able to deal with what infection
remains in the lymphatics and other soft tissues. It is
postulated that the cartilage acts as a barrier to the
spread of infection into the cancellous bone. The
Fig. 125. Syme's amputation. A Shirley drain is pulled into the

wound through a separate stab incision. A clamp is pushed through
the soft tissue below the tibiofibular syndesmosis and the skin is
cut over the tip of the clamp. The white tube carries irrigating fluid.
Drainage is to gravity through the larger tube which is perforated at
the end in the wound.
Fig. 127. Syme's amputation, first stage. A walking cast is applied

Fig. 126. Syme's amputation. Closure of skin with nonabsorbable at 10 to 14 days following surgery. The space on either side of the
sutures. The dog ears are not trimmed; gangrene has resulted from soft tissue outline is from a felt pad which has a hole cut in the
narrowing the flap in trimming the dog ears. center for relief of pressure over the dog ears.
Fig. 129. Syme's amputation, second stage. The dog ears are
removed through elliptical incisions around the base. Local anes-
thesia can be used if there is any contraindication to general
anesthesia.
Fig. 128. Syrne's amputation. A walking cast is used following

both first and second stages for protection of the tissues during
healing and lor mobilization of the patient.
original description of the two-stage method in 1954

appears to bear this out.
The second stage is the definitive amputation and
is performed 6 to 8 weeks after the first stage. The
dog ears are still prominent and the bony prominences
of the malleoli could produce pressure sores if not
removed.
Technique. Elliptical incisions are made at the bases
of the dog ears (Fig. 129). Local anesthesia can be
used if general anesthesia is contraindicated by the
general condition of the patient. The tissue removed
should be about equal to the volume of the malleolus.
Both malleoli are exposed subperiosteally (Fig. 130)
and removed flush with the plafond of the tibia (Fig. Fig. 130. Syme's amputation, second stage. The malleolus is
131). The edges of tibia and fibula are removed to outlined sharply. A similar procedure is carried out on the opposite
smooth the sharp angles that remain (Fig. 132). The malleolus.
pad is tested before closure and, if it is too loose,
additional soft tissue is removed from the ellipitical nonwalking cast is applied. A t 1 0 days, a walking cast
incision. The deep fascia of the heel pad is sutured to is applied. The limb is usually ready for a prosthesis
the periosteum of the tibia and fibula. If the pad is still at 8 to 1 2 weeks (Figure 134).
loose, drill holes are placed in the tibia and fibula. Single-stage procedure-technique. The incision
Fixation of the pad through these drill holes produces starts at the tips of the malleoli and goes across the
a stable pad. During closure of the subcutaneous fat, dorsum at the ankle joint and then straight down
the sutures are offset as necessary to level the skin. across the sole. The technique is exactly the same as
Final closure is with nonabsorbable sutures (Fig. 133). the two-stage method up through the removal of the
A light compression dressing is applied. At 3 days, a foot. Then the malleoli and distal portion of the tibia
Fig. 131. Syme's amputation, second stage. The lateral malleolus

is removed flush with the plafond of the tibia. Articular cartilage is
not removed. The lateral flare is to be smoothed.
Fig. 133. Syme's amputation, second stage. The dog ears and
malleoli have been removed and the flares smoothed. Closure is
completed.
Fig. 132. Syme's amputation, second stage. The flare of the distal
tibia has been removed.
are freed up subperiosteally to 1 cm above the ankle

joint. With an amputation saw, the tibia and fibula are
sawn through on a line perpendicular to the weight-
bearing line. If there were much tibial curvature or
other angulation, an osteotomy directly across the
ankle joint would not be parallel to the floor and would
put excessive strain on the heel pad. The level of tibial
osteotomy is such that a small circle of cartilage is left
at the dome of the plafond. After hemostasis and Fig. 134. Syme's amputation. A well-healed stump that is ready
for a definitive prosthesis. The medial lateral diameter has been
tidying of the pad are complete, the pad is manually narrowed slightly by removal ot the distal flares of the tibia and
folded against the tibia. If it is too loose, additional fibula. Suspension is provided by the anterior and posterior flares
tissue is removed. The dog ears are not disturbed so which remain.
Foot 13Ankle/Vol. 2, No. 2 THE DYSVASCULAR FOOT 117
that circulation to the posterior skin is not compro- based on the degree of use and any change in shape
mised. The dog ears shrink down and mold well into of the stump due to atrophy.
the sides of the residual limb with continued casting. Some elderly patients are wheelchair-bound be-
Several drill holes are made in the anterior edge of cause of other disabilities such as organic heart dis-
the tibia. The deep fascia of the pad is anchored ease or cerebrovascular accident. They may still per-
through these holes, as the pad is centered and form standing transfers, and may void better in a
aligned with the tibia. The balance of the closure is standing position. A light boot-like prosthesis has
the same as in the second stage. The cavity is irrigated been fashioned over a foot of polyurethane foam (Fig.
through the Shirley drain for 24 to 48 hr. A non- 136). It is fastened with Velcro straps. It provides
weightbearing cast is used for 2 weeks. A weighbear- excellent protection to the stump for this minimal
ing cast is then applied and continued for approxi- amount of use.
mately 8 to 12 weeks until the stump has matured
Calcanectomy
enough for fitting of the prosthesis (Fig. 134).
Prosthetic Fitting. The double-walled balloon pros- The dysvascular foot is susceptible to pressure
thesis has been quite satisfactory (Fig. 135). There areas around the calcaneus. We have had varied
are no buckles, straps, loose parts, or windows. Oc- success with partial and total calcanectomies. Our
casionally, a patient will require a suprapatellar strap success rate is higher with neurological patients with
to aid in suspension. The patellar tendon-bearing spinal cord injury where the vascular function is less
(PTB) brim can be adjusted to aid in proximal weight compromised. However, with further experience, our
relief if necessary. It also aids directly in rotational success rate is increasing with the diabetic and dys-
control. The first definitive prosthesis usually lasts 9 vascular patients.
to 12 months. At this time, there has been enough Indications. A calcanectomy is indicated for gangre-
shrinkage of the stump so that more stump socks are nous or infected pressure areas over the 0s calcis of
needed. At this stage, new prostheses are ordered, such a size that a Syme's amputation is not possible
Fig. 135. Syme's amputation. double-walled prosthesis. Entry of

the bulbous end of the stump is possible with expansion of the
elastic panel in the inner wall. Suspension is provided by the
anterior and posterior contours which are held against the stump
by the elastic panel. Plantarflexion after heel strike is simulated by Fig. 136. Syme's amputation. A prosthesis which is made far
compression of the rubber cushion wedge in the heel. Ankle and minimal function. This is formed over a plastic foot. Velcro strap
metatarsophalangeal joint motion is simulated by the rocker bottom closure provides enough stability for wheelchair and bathroom
contour of the foot and the flexibility of the toe block. transfers .
even with resection and closure of the ulcer. With

removal of the 0s calcis, the flaps must be sufficiently
long to close without tension. The patient must be an
ambulatory candidate. The ischemic index must be
over 0.45 in the posterior tibia1 artery.
Technique. The ulcer is outlined by an elliptical
incision. If there is infection in the midplantar space,
this must be evacuated also (Fig. 137). The 0s calcis
is dissected out sharply. The tendo Achillis is sec-
tioned above the area of infection. The capsule of the
subtalar joint is divided posteriorly to begin removal
of the 0s calcis. The intertarsal ligament is divided
and, as the bone is swung out of the foot, the calca-
neocuboid joint capsule is divided along with the bi-
furcate ligament. The anterior subtalar joint capsule is
divided and the 0s calcis removed. The wound is
inspected and all infected and devitalized tissue re-
moved. A Shirley drain is brought into the wound
through a separate stab incision. The skin and sub-
cutaneous tissue only are closed (Fig. 137). Irrigation
is continued for 3 to 1 0 days, depending upon the
character of the fluid exiting the wound. When the
fluid is clear, it is cultured and irrigation is stopped.
Systemic antibiotics are continued, based on preop-
erative cultures, and changed as indicated by subse-
quent cultures and sensitivities taken from the wound
just before closure and then from the irrigation fluid.
After the drain is removed, (fig. 138) the foot is
placed in a non-weightbearing cast. When the wound
appears secure and sutures have been removed, a
weightbearing cast is applied. At about 6 to 8 weeks
Fig. 137. The sole of the foot following calcanectomy and evacu-
postoperatively, an ankle-foot orthosis is prescribed. ation of a midplantar abscess. A nonwalking cast has just been
The tendo Achillis gradually reattaches to the deep removed.
fascia of the heel. Plantarflexion power of some de-
gree is gradually reestablished. An occasional patient
has been able to discard the orthosis after 6 months.
These patients have even used a foamed polyethylene
heel pad in a regular shoe.
GRADE FIVE FOOT
Algorithm for Grade Five foot, gangrene of the

whole foot (Fig. 139). Amputation above the ankle
level is necessary in Grade Five lesions. The gangrene
can be wet or dry and the patient's general condition
can range from just barely ill to near death. The patient
is prepared for surgery by vigorous medical treatment.
Many patients with this severe degree of involvement
are older and have associated disease of the cardio-
vascular and renal system. When they are not suitable
for general anesthesia, major amputations have been
performed under local, regional intravenous, and re-
gional nerve block anesthesia. These patients com- Fig. 138. Lateral view of foot following calcanectomy. The patient
prise most of the group that finally require an above will now go into a walking cast. This will b e followed by a polypro-
the knee amputation. pylene ankle-foot orthosis.
GRADE P
GANGRENE OF
WHOLE FOOT
AFEBRILE, WBC
v ELECTIVE AMPUTATION
TREATMENT BED AT LEVEL INDICATED
REST, ELEVATION, BY DOPPLER
CULTURES, SENSITIVITIES, EXAMINATION
X RAY, IV ANTIBIOTICS,
CONTROL UNDERLYING
DISEASE /
I""
LEVEL INDICATED BY DOPPLER INDICATED
EVALUATION AND CONDITION M
NEXT LEVEL
Fig. 139. Algorithm for Grade Five foot. Gangrene of whole foot. Amputation must be performed at least at the below the knee level
PROPHYLACTIC SURGERY Standard bunion and bunionette operations, meta-

tarsal osteotomies, and similar procedures are all
Pressure over bony prominences is the major direct
cause of open lesions in the dysvascular foot. De- used. Claw toe repair frequently reduces metatarsal
head pressure. The Jones reconstruction for clawing
crease in circulation certainly plays a major role in the
of the great toe is quite effective in reducing first
healing of such lesions, but as can be seen from all of
the preceding cases, it takes less blood flow to keep metatarsal head pressure.
a foot going when the skin is closed than it does when ILLUSTRATIVE CASE
there is an open lesion. Relief of pressure concentra-
tions prevents breakdown of tissue. If it cannot be A 48-year-old male executive arrived with a small
done with shoe modifications and similar pressure- ulcer under his first metatarsal head 1 0 years follow-
relieving devices, then it should be done surgically. ing onset of diabetes mellitus. The ulcer cleared rap-
The timing of such surgery is frequently difficult. idly with walking-cast treatment. The deformities pres-
There are certain feelings of "don't rock the boat" ent are well illustrated in Figures 140 and 141. Hy-
and "if it's doing all right, let it alone" with both perextension contractures at the metatarsophalangeal
patients and surgeons. The final decision can finally joints produce relatively depressed metatarsal heads.
rest almost on grounds that are philosophical rather Flexion deformities at the proximal interphalangeal
than medical. joints create bony prominences quite susceptible to
Our policy now is to consider surgical correction of shoe pressure. There is loss of hair growth on the
deformity in any patient who has had an ulcer that has phalanges.
healed with nonoperative treatment. The patients are Doppler indexes are 1 .O at the calf and foot and
carefully observed during their subsequent treatment 0.90 at the toes. A Jones procedure was done on
with shoe corrections. Recurrence of severe calluses, each great toe with fusion of the interphalangeal joint
inability to relieve pressures with appliances, and any (Fig. 142). The lateral proximal interphalangeal joints
sign of tissue breakdown are all indications of the were fused after generous removal of the heads of the
possible need for surgical correction. proximal phalanges (Fig. 143). lntramedullary Kir-
Fig. 140. Marked clawing of all of the toes Fig. 143. Dorsal view after interphalangealjoint fusion of the great
toe and proximal interphalangeal joint fusion of the lesser toes
Contrast position of the toes with Figure 140.
schner wires were used for fixation. Postoperative

protection consisted of a walking cast for 6 weeks,
followed by wooden-soled canvas shoes. The patient
has worn regular shoes for the past 6 years with no
corns or calluses or other signs of pressure in his feet.
The change in the metatarsal fat pad between Figures
141 and 142 is evidence of the shift of internal pres-
sure.
SUMMARY
1. Grading of the dysvascular foot permits a more

systematic approach to prophylactic and direct treat-
ment of toot lesions.
2. Algorithms (flow charts) provide decision-mak-
Fig. 141. Lateral view. Note distal shift of fat pad and hyperexten- ing aids for the simplest to the most difficult foot
sion of the metatarsophalangeal joint. problem presented.
3. The ischemic index obtained with the aid of
noninvasive transcutaneous Doppler Ultrasound pre-
dicts healing levels, both operative and nonoperative,
with a high degree of accuracy.
4. A team approach provides the expertise of many
medical specialties and paramedical groups to insure
continuity of care.
5. Prophylactic surgery can be performed on the
dysvascular foot and will obviate many later problems.
6. Revascularization surgical procedures are suc-
cessful in a high percentage of cases in treating
symptoms of claudication and rest pain. Healing of
foot and ankle ulcers, performance of foot debride-
ment and ablative surgery, and healing of lower levels
of major amputation are all aided by restoration of
some degree of arterial flow.
Fig. 142. Lateral view following Jones procedure with fusion of 7. Direct treatment of atherosclerosis, the under-
the interphalangeal joint of the great toe. Note looseness of the lying cause of the great majority of dysvascular prob-
metatarsal fat pad when contrasted with Figure 141 lems, still awaits further research on etiology and
pathogenesis. The efficacy of a national diet, exercise, Cornpr. Ther., 557-64, 1979.
drug, and nonsmoking program is still unproven and 6. Barnes, R.W., Shanik, G.D., and Slaymaker, E.E.: An index
of healing in below-knee amputation: Leg blood pressure by
not ready for enactment into law.
Doppler ultrasound. Surgery, 79:1320, 1976.
8. Individual responsibility of the patient is the most 7. Burgess, E.M., and Marsden, F.W.: Major lower extremity
important philosophical point to be stressed. All of the amputation following arterial reconstruction. Arch. Surg., 108:
protective shoewear and successful restorative sur- 655-660, 1974.
gery are of virtually no value unless the patient uses 8. Carter, S.A.: The relationship of distal systolic pressures to
healing of skin lesion with arterial occlusive disease with spe-
them properly. In essence, the patient must become
cial reference to diabetes rnellitus. Scand. J. Clin. Lab. Invest..
part of the treatment team. [SUPPI. 1281 31 :239-243, 1973.
Acknowledgments. The system of treatment pre- 9. Chopra, J.A., Hurwitz, L.J., and Montgomery, D.A.D.: The
sented is the accumulation of over 30 years of expe- pathogenesis of sural nerve changes in diabetes rnellitus.
rience. Some of the ideas have been original and Brain, 92:391-418, 1969.
10. Collens, W.S., Vlahos, E., Dobkin, G.B., Neumann, E . , Ra-
developed by the author; some have been obtained kow, R.K., Actman, M., and Siegman, F.: Conservative man-
from other sources. With the passage of time, the line agement of gangrene in the diabetic patient. J.A.M.A., 181:
between the two becomes dim. 692-698, 1962.
All of the statistical data have been gathered by the 11. Cutler, B.S., Thompson, J.E., Kleinsasser, L.J., et al.: Autog-
many fellows and residents who have trained on this enous saphenous vein femorpopliteal bypass: Analysis of 298
cases. Surgery, 79:325-331, 1976.
service since 1969. Concepts of the vascular system, 12. Dale, G.M.: Syme's amputation for gangrene from peripheral
normal and pathological, have been gathered in dis- vascular disease. Artif. Limb, 6:44, 1961.
cussion with physiologists, cardiologists, and vascular 13. Degenhardt, D.P., and Goodwin, M.A.: Neuropathic joints in
surgeons from all over the world. Suffice it to say that diabetes. J. Bone Joint Surg.. 42B:769-771, 1960.
14. Dry, T.J., and Hines, E.A.: Role of diabetes in the development
it is impossible to include the names of all who have
of degenerative vascular disease with special reference to
provided some input. incidence of retinitis and peripheral neuritis. Ann. Intern. Med.,
Continued thanks must go to the nursing staff, cast 14:1893, 1941.
technicians, vascular technicians, occupational ther- 15. Ecker, M.D., and Jacobs, B.S.: Lower extremity amputations
apists, physical therapists, medical social workers, in diabetic patients. Diabetes, 19:189, 1970.
16. Ellenberg, M.: Diabetic neuropathy: Evaluation of factors in
psychologists, medical photographers, attendants
onset. Ann. N. Y. Acad. Sci., 82:245-250, 1958.
and ward clerks, and all the other personnel who aid 17. Fagerberg, S.E.: Diabetic neuropathy: A clinical and histolog-
in restoring continued function for the patient with ical study on the significance of vascular affections. Acta Med.
dysvascular foot problems. Scand., [Suppl.] 345:164, 1959.
Special acknowledgment must go to Alice Bessman, 18. Goldner, M.G.: The fate of the second leg in the diabetic
amputee. Diabetes, 9:100, 1960.
M.D., Diabetologist, Co-Chief of the Ortho Diabetes
19. Goodman, J., Bessman, A.N., Teget, B., and Wagner, F.W.,
Service; John Rosental, M.D., Vascular Surgeon; Clair Jr.: Risk factors in local surgical procedures for diabetic gan-
Stiles, M.D., Chief of Anesthesiology; Phillip Kwong, grene. Surg. Gynecol. Obstet., 143:587-591, 1976.
M.D., Orthopaedic Fellow, then Assistant Chief of 20. Greenbaum, D., Richardson, P.C., Salmon, M.V., and Urich,
Ortho Diabetes, now Chief of Foot Service at Los H.: Pathological observations on six cases of diabetic neurop-
athy. Brain, 87:201-213, 1964.
Angeles Orthopaedic Hospital; Richard Chambers,
21. Gunderson, J.: Diagnosis of arterial insufficiency with mea-
M.D., Orthopaedic Fellow, then Assistant Chief, and surement of blood pressure in fingers and toes. Angiology, 22:
now assuming role of Chief of Ortho Diabetes; Richard 191, 1971.
Voner, C.P.O., Prosthetist; Warren Waite, C.O., Or- 22. Harmon, J.W., and Hoar, C.S.: Cloth femoral-popliteal bypass
thotist; Charles Marsden, C.P., Pedorthist; and Marian grafts in 29 diabetic patients. Arch. Surg., 106:282-285,
1973.
Karsjens who prepared the final manuscript.
23. Harris, R.I.: Symes's amputation: The technical details essen-
tial for success. J. Bone Joint Surg., 38B:614, 1956.
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Foot & Ankle International http://fai.sagepub.

The Dysvascular Foot: A System for Diagnosis and Treatment

The online version of this article can be found at:

American Orthopaedic Foot & Ankle Society

Email Alerts: http://fai.sagepub.com/cgi/alerts

>> Version of Record - Sep 1, 1981

The Dysvascular Foot: A System for Diagnosis and Treatment

F. William Wagner, Jr., M.D. *

Orthopaedic treatment of the dysvascular foot and 2. Chronic chilblains (pernio)

GRADE I GRADE 2 GRADE 3 GRADE 4 GRACE 5

ne patient to the physician are claudication, rest pain,

There is a superficial ulcer without penetration to

Deeper tissues are involved and there is abscess,

Fig. 4. Grade One lesion after first walking-cast treatment (final

An algorithm is an ordered sequence of mathemat-

There is gangrene of some portion of the toe, toes,

Gangrene involves the whole foot or enough of the

ALGORITHM OR FLOW CHART

Algorithm and flow chart are terms borrowed from

counseling etc. The arrow then directs progression to

indicated level, and for patients with claudication and

Diagnostic X-rays aid in the detection of osteomye-

calization of tumors and infectious processes can be

treatment. In addition, house calls may be made to Pedorthist

Psychologist Occupational Therapist

Ordering a prosthesis is dependent on input from Physical Therapist

Fig. 12. Algorithm for Grade Zero foot, no open lesions.

NORMAL DOPPLER SHIFT NORMAL DOPPLER SHIFT

ISCHEMIC INDEX In order to determine the efficacy of the index, 71

ARM B P = 120 rnrntig 0 HEALING

Fig. 16. Plethysmograph cuff used to obtain pressure at big toe.

14, the blockage is in the superficial femoral artery.

Although this review is not intended to teach vas-

Total 277 93 98 96 KNEE

ischemic index is, thus, over 1 .O. In cases of this type,

I20 I:, A& 120

Fig. 21. Common iliac artery almost completely blocked. One-

reduced to 0.67. Mild symptoms of claudication may

70 _/L &, ..... 1 2 ~

chance for false aneurysm which does occur in end-

Fig. 31. Femoro-femoral bypass with open contralateral common

are not present, Dacron, other synthetic grafts, or

profunda femoris artery supplies the major portion of

Fig. 32. Aortofemoral popliteal segmental bypass.

The list of unsatisfactory materials is long. New ones

DISTAL "RUN-OFF:" GOOD

%&- f l J 2 (-) NON-PULSATILE FLOW

VASCULAR EVALUATION STUDY REVEALED 02 . ~ F F C L ~ ~ C NAME

WOUND HEALING LEVEL (PHYSIQIOGIC)

ROOM 106, CLINIC BLDG , RLAH - ~ /omm.Y

tibia. A KritterZ7drain was used to irrigate the wound

competent distal valve closed, the blood is forced

Fig. 37. Fork-lift truck injury to foot with complete destruction of

Fig. 38. X-ray examination showing complete loss of bony conti-

the involved part. There are patients with rest pain

patient was walking several blocks a day. At 3 months,

Fig. 42. Immediate postoperative condition. A Shirley two-lumen

Fig. 41. Dorsal view of foot with gangrene of most of forefoot

Fig. 46. Patchy involvement of superficial femoral arteries with

Fig. 44. Abdominal portion of angiogram showing clear renal

is planned at 18 months. Similar results have been

Fig. 50. Fractures of second and third metatarsals from mild

Fig. 52. Charcot disruption of the naviculo-cuneiform area of right

ation which is infected, it is difficult to distinguish X-