BACKGROUND■ Tumors of the foot and ankle are rare.3,7,10,12,15,16 In thesenior author’s experience, 153 cases were treated.■ FIGURE 1A shows all anatomic sites, FIGURE 1B showsthe distribution of malignant and benign cases, and FIGURE1C shows the distribution of all types of surgical procedures.■ Patients with tumors of the metatarsals complain of painwith an associated mass. The mass may be small and chronic.It may be first noticed after a minor injury. The patient mayhave difficulty with weight-bearing activities, including walk-ing and standing. Shoe wear, particularly fashionable shoes,may be limited.■ Physical examination often shows a tender mass localized tothe metatarsal with some swelling. If a sensory nerve overliesthe mass, there may be paresthesias. If the mass is large, theremay be loss of motion, or discomfort with active range of mo-tion of the foot and ankle.■ For extensive disease of the forefoot involving the first andsecond interspace in adjacent metatarsals or multiplemetatarsals, a Lisfranc amputation or a transmetatarsal amputa-tion is indicated (FIG 2A–C). These amputation levels are highlyfunctional with minor shoe-wear modifications and forefootfillers. If the metatarsal bases can be preserved using a trans-metatarsal amputation, the functional outcome is improved.■ Careful preoperative evaluation is necessary, and MRI is es-pecially important to assess the extent of marrow change in themetatarsals to ascertain the appropriate level of amputation.■ For tumors extending to the tarsometatarsal joint with softtissue extension, a Chopart amputation is a consideration. TheChopart amputation is a transtarsal amputation that preservesthe talus and calcaneus. The disadvantage of the Chopart am-putation is the loss of the dorsiflexors of the foot, which al-lows unopposed action of the Achilles tendon, resulting in anequinus contracture.■ To circumvent this problem, the tibialis anterior is used. Itis detached from the tarsal navicular with a cuff of soft tissue,preferably periosteum. A drill hole is made through the neckand head of the talus in an oblique fashion from dorsolateralto plantar-medial. The tendon is then routed through this bonetunnel and sewn to itself or soft tissue as it exits through thetunnel. This repair may be augmented with bone anchorsplaced near the dorsal opening of the tunnel. The residual footis maintained in maximal dorsiflexion (FIG 2D,E).■ The advantage of a Chopart amputation over a Syme ampu-tation is the maintenance of hindfoot height. This is an end-bearing residual limb and the patient can negotiate shortdistances without modified shoe wear or prosthetic fitting.

ANATOMY■ The Lisfranc joint is the tarsometatarsal joint. An amputationat this level will preserve the dorsiflexors and plantarflexors.

■ The Chopart joint is also known as the transverse tarsaljoint. It includes the talonavicular and calcaneocuboidjoints. An amputation at this level preserves the plantarflex-ors but sacrifices the dorsiflexors, often resulting in an equi-nus contracture.

INDICATIONSLisfranc■ Extensive tumor involving the first and second interspace inadjacent metatarsals or multiple metatarsals

Chopart■ Tumors extending to the tarsometatarsal joint with soft tis-sue extension. FIGURE 3 shows the pathology specimen afterwide resection of a chondrosarcoma involving multiple smallbones of the foot.

IMAGING AND OTHER STAGINGSTUDIES■ Preoperative studies include plain radiographs of the foot,including anteroposterior, lateral, and oblique views. If thereis involvement of the ankle joint, then anteroposterior andmortise views are obtained as well. MRI is important to eval-uate the amount of involvement of the metatarsals to deter-mine the level of amputation. It also shows the extent of softtissue tumors and may be helpful in distinguishing benignfrom malignant tumors.17

■ MRI is helpful for assessing soft tissue involvement.FIGURE 4A,B shows a chondrosarcoma of the calcaneus, andthe MRI shows extension into the soft tissue. It was treatedwith cryosurgery but recurred, and a below-the-knee amputa-tion was performed.■ FIGURE 4C,D shows an example of a unilateral calcanealbrace (UCB). The radiograph shows the typical expansile ap-pearance of the UCB. The CT scan shows greater bony detail.The lesion was treated with curettage, graft, and polymethyl-methacrylate (PMMA).

SURGICAL MANAGEMENT■ The goal of the surgical procedure is remove the tumor withadequate margins. FIGURE 5 illustrates a case of osteosar-coma of the calcaneus. Osteosarcoma is usually treated withwide resection, but in this case the tumor was confined to thecalcaneus. The patient had a good response to adjuvantchemotherapy, with 100% tumor necrosis, and was treatedwith the only calcaneal prosthesis reported in the world.■ A long plantar flap is important for a sturdy end-bearingstump.■ The quality of the tissue is more important than the quantity.1■ The bony edges should be smooth and beveled if possible. Anexample is the Lisfranc amputation, in which the cuneiforms

Chapter 42Loretta B. Chou, H. Thomas Temple, Yvette Ho, and Martin M. Malawer

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FIG 1 • A. All anatomic sites of tumors of the foot andankle (n � 153). B. Distribution of malignant and be-nign tumors of the foot and ankle (n � 153). C.Distribution of surgical procedures for tumors of thefoot and ankle (n � 153).

A

B C

A B C

FIG 2 • Chopart amputation has a poor reputation because many patients develop an equinus contracture. Withtransfer of the tibialis anterior to the neck of the talus, this problem can be avoided. This case is an example of syn-ovial sarcoma involving the forefoot. A. This patient’s radiographs showed radiodensity surrounding the secondmetatarsal, a typical radiographic appearance of a synovial sarcoma. B,C. MRI shows extensive soft tissue mass. Thepatient was treated with a Chopart amputation. (continued)

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FIG 2 • (continued) D. Postoperative photograph showsgood dorsiflexion function. E. Chopart amputation canbe successful with the transfer of the tibialis anterior intothe talar neck. This patient also had a Marcaine catheterplaced for postoperative pain control (A).D E

FIG 3 • Chondrosarcoma can spread to involve multiple sites.This photograph shows the pathology specimen after a belowknee amputation of a chondrosarcoma involving multiple smallbones of the foot.

A B

FIG 4 • Chondrosarcoma of the calcaneus. A,B. MRI shows extension into the soft tis-sue. It was treated with cryosurgery but recurred, and a below-knee amputation wasperformed. C,D. UCB of the calcaneus. The radiograph shows the typical expansile ap-pearance of the UCB. The CT scan shows greater bony detail. The lesion was treatedwith curettage, graft, and polymethylmethacrylate.

C D

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should be contoured to a rounded end. In a Chopart amputa-tion, the talus and calcaneus should be cut and contoured to fita prosthesis.■ Myodesis is helpful to pad the end of the stump.■ Reconstruction of the anterior tibialis tendon insertion intothe neck of the talus in the Chopart amputation will help pre-vent an equinus contracture.

Preoperative Planning■ Preoperative planning is crucial for a good outcome. Thepreoperative radiographs and CT and MRI studies are im-portant to determine the amount of tumor involvement. Theresults of the biopsy will determine the level of amputation.

Positioning■ The patient is placed supine on the operating table. A thightourniquet is placed over adequate padding, such as Webril. Abump may be placed proximal to the sciatic notch on the ipsi-lateral hip to limit external rotation of the extremity duringthe procedure.

Approach■ Lisfranc and transmetatarsal amputations are performedthrough a midfoot incision, with a long plantar flap. This isthe same approach with the Chopart amputation. The plantarskin is thicker and has specialized columns of plantar fat toprovide for a weight-bearing stump.

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FIG 5 • Osteosarcoma is an aggres-sive malignant tumor that has beenreported to occur in the calcaneus.Osteosarcoma is usually treated withwide resection, but in this case thetumor was confined to the calcaneus.The patient had a good response toadjuvant chemotherapy, with 100%tumor necrosis, and was treated withthe only calcaneal prosthesis reportedin the world. The lateral radiograph(A) shows the expansile tumor. Thebone scan (B) shows isolated involve-ment. Postoperatively, at 10 years,the patient is tumor-free and enjoysworking and normal activities (C,D).

TRANSMETATARSAL AMPUTATION■ A transverse incision is made either at the middle or

proximal third of the metatarsals, extending throughskin into the subcutaneous tissue (TECH FIG 1A,B).

■ The cutaneous branches of the terminal portions of theperoneal nerve are identified. Traction is applied, pullingthe nerve distally. The nerve is transected sharply toallow it to retract proximally.

■ The terminal branch of the dorsalis pedis is preserved ifpossible to maintain continuity of the anastomosis with

the posterior tibial terminal arterial branch, thus main-taining the dorsalis pedis contribution of arterial flowthrough the arch.

■ The extensor tendons are placed on a stretch, and this isbest accomplished by flexing the forefoot and sharply di-viding the tendons at the level of the skin incision, allow-ing the tendons to retract proximally.

■ A beveled cut is made in the metatarsal heads by anglingan oscillating saw 30 degrees from the perpendicular

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LISFRANC AMPUTATION■ A transverse incision is made either at the middle or

proximal third of the metatarsals, extending throughskin into the subcutaneous tissue (TECH FIG 1C,D).

■ The cutaneous branches of the terminal portions of theperoneal nerve are identified. Traction is applied, pullingthe nerve distally. The nerve is transected sharply toallow it to retract proximally.

■ The terminal branch of the dorsalis pedis artery is ligatedand divided as it enters the first dorsal interspace andcourses in the plantar fascia.

■ The extensor tendons are placed on a stretch; this is bestaccomplished by flexing the forefoot and sharply dividingthe tendons at the level of the skin incision, allowing thetendons to retract proximally.

with the foot placed in neutral position on the operatingtable. A plantar flap is then fashioned by extending theincision through the skin approximately 45 degrees fromthe transverse dorsal incision obliquely across the medialand lateral foot to the level of approximately themetatarsal heads and then transversely across the skinjust proximal to the metatarsal heads.

■ The sensory nerve to the first ray is identified, traction isplaced, and the nerve is transected sharply. The terminalbranches in the medial plantar nerve are identified aswell, placed on stretch, and sharply divided. The terminalbranches of the medial plantar artery are identified, lig-ated, and divided.

■ The superficial and deep flexor tendons are placed onstretch by dorsiflexing the forefoot through themetatarsal osteotomies and sharply dividing them, al-lowing them to retract proximally. No attempt is made

to suture the extensor tendons to the flexor tendons.■ If there is a significant plantar extension of the tumor, a

long plantar flap cannot be used. In this case, a fish-mouth configuration is preferable. To achieve this, equaldorsal and plantar flaps are constructed and the sameoperation is carried out as indicated above.

■ The tourniquet is deflated and meticulous hemostasis isobtained. Excessive use of cautery to obtain hemostasis isdiscouraged to limit dysvascularity of the plantar flap.

■ The plantar flap is brought up and myodesed to theresidual metatarsals or tarsal bones. Alternatively, theplantar fascia can be sewn into the periosteum overlyingthe residual metatarsal heads or capsular structures inand around the tarsal bones.

■ The skin is closed with 4-0 nylon sutures. A Penrose drainis placed deep to the flap and brought out either medi-ally or laterally through the incision.

A B

TECH FIG 1 • A,B. Surgical technique for transmetatarsal amputation. Dorsal and plantar skin incisions. Bonecuts are made with a sagittal saw.

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E F

TECH FIG 1 • E,F. Surgical technique for Chopart amputation. Skin incisions with dorsal and plantar flaps.Dissection and removal of bones. Attachment of tibialis anterior tendon into the neck of the talus throughdrill holes. Wound closure with sutures.

C D

■ The Lisfranc joint is disarticulated sharply. A plantar flapis fashioned by extending the incision through the skinapproximately 45 degrees from the transverse dorsalincision obliquely across the medial and lateral foot tothe level of the distal metatarsals.

■ The sensory nerve to the first ray is identified, traction isplaced, and the nerve is transected sharply. The terminalbranches in the medial plantar nerve are identified,placed on stretch, and sharply divided.

■ The terminal branches of the medial plantar artery areidentified, ligated, and divided. The superficial anddeep flexor tendons are placed on stretch by dorsiflex-ing the forefoot through the Lisfranc joint and sharplydividing them, allowing them to retract proximally. Noattempt is made to suture the extensor tendons to theflexor tendons.

■ If there is a significant plantar extension of the tumor, along plantar flap cannot be used. In this case, a fish-mouth configuration is preferable. To achieve this, equaldorsal and plantar flaps are constructed and the sameoperation is carried out as indicated above.

■ The tourniquet is deflated and meticulous hemostasis isobtained. Excessive use of cautery to obtain hemostasis isdiscouraged to limit dysvascularity of the plantar flap.

■ The plantar flap is brought up and myodesed to thetarsal bones. Alternatively, the plantar fascia can besewn into the periosteum overlying the capsular struc-tures in and around the tarsal bones. The skin is closedwith 4-0 nylon sutures, and a small drain is placed deepto the flap and brought out either medially or laterallythrough the incision.

CHOPART AMPUTATION■ The Chopart amputation is performed through a trans-

verse incision that is dorsally based at or just distal to thetalonavicular joint (TECH FIG 1E,F).

■ The dorsalis pedis artery and accompanying nerve areidentified. The dorsalis pedis artery is ligated and di-

vided, and the sensory nerve is placed on stretch andtransected sharply, allowing it to retract proximally.

■ The capsule of the talonavicular joint is circumferentiallydivided, along with release of the posterior tibial ten-don. This tendon is tagged for later use as it is brought

TECH FIG 1 • C,D. Surgical technique for Lisfranc amputation. Skin incisions on the dorsaland plantar aspects of the foot. The plantar skin flap is longer. Dissection and removal ofthe metatarsals. Wound closure with sutures.

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through the interosseous membrane and reattached tothe neck of the talus with suture anchors or through ahole drilled in the talus as described above.

■ An alternative solution is to place the posterior tibialtendon through the interosseous membrane with themedial half of the Achilles tendon. The Achilles tendon isthen suture-anchored to the neck of the talus and usedto augment the tibialis anterior or posterior tibial ten-don. Achilles lengthening is also a helpful technique be-cause it reduces the stress on the tibialis anterior. TheAchilles tendon is not necessary for normal ambulationdue to the lack of forefoot.

■ A long plantar flap is preferred, but if the tumor extendsinto the plantar base and soft tissues, a fish-mouth inci-sion is made with equal-length dorsal and plantar flaps.

■ To help prevent equinus contracture, the tibialis anterioris detached from the tarsal navicular with a cuff of softtissue, preferably periosteum. A drill hole is madethrough the neck and head of the talus in an obliquefashion from dorsolateral to plantar-medial. The tendonis then routed through this bone tunnel and sewn to it-self or soft tissue as it exits through the tunnel. This re-pair may be augmented with bone anchors placed nearthe dorsal opening of the tunnel.

■ The residual foot is maintained in maximal dorsiflexionduring this repair. Figure 2E shows the position of theankle after the amputation and reconstruction of thetibialis anterior into the talus. Several additional proce-dures are required for a functional Chopart amputation.Contracture prevention is critical and ensured throughtransfer of the extensor tendons to the dorsum of thefoot and lengthening of the Achilles tendon.5

■ The posterior tibial tendon and the flexor hallucis longusand brevis tendons are divided; the tendons are allowedto retract proximally unless the posterior tibial tendon isused to augment the dorsiflexion repair.

■ The plantar branch of the posterior tibial artery is lo-cated, ligated, and divided. The flaps are maintainedwith sufficient soft tissue to keep them as thick as possi-ble to prevent devitalization of the skin.

■ If the head of the talus is prominent, a portion of thisbone can be removed in a beveled fashion by using anoscillating saw and angling the blade 30 degrees fromdistal proximal to plantar distal. The calcaneocuboid ar-ticulation is generally divided, but if part of the cuboidcan be maintained, this is preferable. Contouring the dis-tal talus and calcaneus will help to decrease the size ofthe stump, and this will help with prosthetic fitting.

■ The repair of the plantar soft tissue to the dorsal soft tis-sue is tenuous as there is no stout tissue dorsally to anchorthe plantar flap. For this reason, a myodesis is preferred;it is performed by drilling holes in the distal talus andresidual cuboid and anchoring the plantar fascia to thedorsal residual bone with 0 nonabsorbable suture. Thesubcutaneous tissue is approximated with 3-0 absorbablesutures and the skin repaired with 4-0 nylon suture.

■ The residual foot must be maintained in as much dorsi-flexion as possible. To help achieve this, a rigid dressingis applied by binding the residual foot from a proximal-plantar to distal-dorsal direction and applying gentle butfirm compression on the residual foot. This rigid dressingis applied and extended up to the proximal leg, main-taining the residual foot and ankle in a maximally dorsi-flexed position to protect the repair.

■ A sciatic nerve catheter is used for intraoperative andpostoperative pain control. General anesthesia is used forthe procedure. The patient is placed into the lateral decu-bitus position with the affected side up. A tourniquet isplaced on the upper thigh. After sterile surgical prepara-tion and draping, an L-shaped incision is made from thetip of the fibula posteriorly and anterior to the Achillestendon. The incision is parallel to the fibula, extendingdistally and making a curve at the border between thedorsal and plantar skin of the calcaneus laterally.

■ The initial skin is incised using the scalpel and dissectionis carried down through the subcutaneous tissue. Theincision and approach are inferior to the peroneal ten-dons, which remain safely superior to the dorsal fasciocu-taneous flap. The sural nerve is also more superior andaway from the operative field. The lateral wall of the cal-caneus is exposed.

■ A corticotomy is made using a drill to open the lateralwall of the calcaneus. The tumor is opened, which allowsfor the curettage. Large curettes are used to remove theobvious tumor material. This is followed by inspectingand burring the edges of the remaining calcaneal wall.Once the resection is completed, the cavity is irrigated toagain inspect the cavity for remaining tumor.

■ To do the cryosurgery, the tourniquet is inflated to 350mm Hg. Gelfoam is used to line the skin edges and subcu-taneous tissue around the wound site. The retractors areplaced over the Gelfoam, and laparoscopic tape spongesare placed around the skin to cover the skin. The foot isplaced into a basin of warm water to try to keep the footwarm to prevent any problems that the decreased tem-perature from the cryosurgery may cause in the unin-volved portions of the foot. Normal saline is poured intothe tumor cavity. Endocare cryosurgery probes are pre-pared on the back table. Ice balls are formed and noted atthe tip of each of the probes. Three- and 5-mm probes areused for the cryosurgery. The cryoprobes are placed intothe tumor cavity and left in to complete a 10-minute cycle.The skin is monitored for necrosis, and warm saline is usedto keep the skin warm and supple. The cavity is allowed tothaw and the tourniquet is deflated.

■ The reconstruction portion of the procedure consists ofan allograft cancellous bone block from the bone tissuebank that is cut and contoured and placed against thesubchondral surface adjacent to the subtalar joint. Twosmall Rush rods are cut, contoured, and placed withinthe calcaneus to extend from the subtalar joint, abut-ting and holding the allograft in place. PMMA is mixed

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PEARLS AND PITFALLSIndications ■ A careful and complete history and physical examination are essential. Preoperative studies

are necessary to plan the resection and reconstruction.

Surgical incision ■ A long plantar flap results in a better end-bearing stump. The natural cascade of metatarsallengths should be maintained.

Wound healing complications ■ Local wound care with dressings and oral antibiotics are usually sufficient to allow for healing.

Deep infection ■ Parenteral antibiotics and surgical débridement may be necessary to treat deep infections.Early diagnosis and treatment can affect outcome.

Contractures ■ Postoperative splinting can help prevent contractures. Once a contracture occurs, it istreated with stretching if mild. Serial casting may be needed.

with 1 g vancomycin on the back table and prepared byhand mixing. This is placed into the tumor cavity to fillthe cavity, completing the reconstruction. The midfootand forefoot are taken through gentle range of motionto ensure normal movement of these joints and tomake sure that there was no iatrogenic extrusion of ce-

ment, which could compromise the motion of thesejoints. Also, the calcaneus is gently axially loaded withhand pressure to ensure that the reconstructed calca-neus moves as a single unit. A drain is placed, and thewound is closed in layers. A plaster splint is used.

SYMES AMPUTATION■ The incision extends from the anterior aspect of the later-

al malleolus to the anterior aspect of the medial malleo-lus, continuing to the plantar skin. The incision at theplantar flap is made to the level of the calcaneocuboidjoint. The soft tissues, including tendons, are incised andallowed to retract; the neurovascular bundle is identifiedand ligated. The talus and calcaneus are dissected sharplyand removed.

■ The surgeon must be cautious at the point of the Achillestendon insertion site: the skin is thin and adherent andmust be protected.

■ The flares of the malleoli are removed with a sagittalsaw. The plantar fat pad is fixed to the end of the stumpwith nonabsorbable sutures into drill holes of the distaltibia and fibula.

■ A drain is placed and the wound closed in layers; 3-0nylon suture is used to repair the skin. A well-paddedsoft dressing is applied.

POSTOPERATIVE CARE■ Postoperative pain control will allow early mobilization ofthe patient. Wound healing without complications and preven-tion of contractures, particularly equinus contractures, arevital.1■ For the Lisfranc and transmetatarsal amputations, a rigidpostoperative dressing is used. The wound is dressed with nonadherent dressing gauze. A gauze roll is used to bind theresidual foot. Cotton padding is then placed in strips from thehindfoot to the forefoot from plantar to dorsal in an attemptto reduce the tension on the suture line. The heel is wellpadded with cotton padding, and then a plaster cast is applied.The cotton padding may have elastic in it for built-in stretch.The plaster is also applied from proximal and plantar to distaland dorsal to reduce the tension on the suture line. The plas-ter application should be firm but not tight. It should be placedin closed-toe fashion and should extend up to the proximalleg, maintaining the residual foot in the neutral position to aslightly dorsiflexed position.■ This initial dressing is changed after 3 to 5 days and thePenrose drain is removed with the first dressing change. A sim-ilar plaster is applied for an additional 2 weeks. At the time of

plaster removal, the sutures are removed. The patient is givena prescription for a shoe filler.■ After 2.5 weeks, the patient’s foot is placed in a buckle-wedge shoe for an additional 3 to 4 weeks. After that, shoewear and progressive ambulation are encouraged.■ After a Chopart amputation, the cast is removed after 5days and the drain is removed. A second dressing and cast areapplied for about 3 weeks. The second cast is removed and thesutures are removed at the end of the 3 weeks. A third cast isapplied and maintained for 6 to 8 weeks. After the final cast isremoved, the patient begins physical therapy to begin range ofmotion, in particular dorsiflexion and plantarflexion excur-sion of the residual foot. A prosthetic measurement is taken.

OUTCOMES■ Patients with a Lisfranc, transmetatarsal, or Chopart ampu-tation have good overall function compared with patients witha Syme amputation.1,11,14 However, patients with an equinuscontracture after a Chopart amputation have inferior results.6,8

■ A Chopart amputation in a young patient is inferior infunction to a Syme amputation due to the lack of ability toreplace forefoot function when the space between the floor

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and the plantar surface is reduced significantly in a Chopartamputation.■ The Chopart procedure provides an excellent level of ampu-tation for a patient with limited activities and goals.1 The mainadvantage to this level is that little is lost between the distalend of the residual limb and the floor. This allows ease of am-bulation without the need for a prosthetic device.13

■ For persons requiring short trips to the bathroom in themiddle of the night or stability for transfers, the Chopart levelis perfect. Unfortunately, the lack of anatomic structure andminimal distance from the plantar surface to the floor makesthe Chopart amputation a poor choice for the active amputee.■ Ambulation is achieved with a foot spacer. For the Chopartstump, a clamshell type of prosthesis allows good weight-bearing function and restores the effective foot length.4■ Generally, patients are able to ambulate 3 months afteramputation using a simple shoe prosthesis.14

■ Gait analysis shows that abnormality and asymmetry ofground-reaction forces were less with a greater preservedstump length.9

COMPLICATIONS■ Wound healing complications are treated with local woundcare, elevation, and non-weight bearing. Oral antibiotics maybe indicated. If there is skin flap necrosis, débridement with askin graft may be necessary.2■ Superficial infection is often resolved with a short course oforal antibiotics.■ Deep infection may require immediate operative débride-ment of devitalized tissue. Parenteral antibiotics are importantto treat this limb-threatening problem. At the time of thedébridement, a bone culture should be ordered to help deter-mine the appropriate antibiotic.■ Equinus contracture is most easily treated by prevention.However, stretching with a therapist may be helpful. Serialcasting may be required to correct the deformity.

REFERENCES1. Berke GM. Lower limb prosthetics. In: Coughlin MJ, Mann RA,

Saltzman CL, eds. Surgery of the Foot and Ankle, 8th ed.Philadelphia: Mosby, 2007:1399–1422.

2. Chang BB, Bock DE, Jacobs RL, et al. Increased limb salvage by the useof unconventional foot amputations. J Vasc Surg 1994;19:341–349.

3. Chou LB, Malawer MM. Analysis of surgical treatment of 33 footand ankle tumors. Foot Ankle Int 1994;15:175–181.

4. Dillon MP, Barker TM. Can partial foot prostheses effectively restorefoot length? Prosthet Orthot Int 2006;30:17–23.

5. Garbalosa JC, Cavanagh PR, Wu G, et al. Foot function in diabeticpatients after partial amputation. Foot Ankle Int 1996;17:43–48.

6. Greene WB, Cary JM. Partial foot amputations in children: a com-parison of the several types with the Syme amputation. J Bone JointSurg Am 1982;64A:438–443.

7. Hattrup SJ, Amadio PC, Sim FH, et al. Metastatic tumors of the footand ankle.Foot Ankle 1988;8:243–247.

8. Heim M. A new orthotic device for Chopart amputees. Orthop Rev1994;23:249–252.

9. Hirsch G, McBride ME, Murray DD, et al. Chopart prosthesis andsemirigid foot orthosis in traumatic forefoot amputation: compara-tive gait analysis. Am J Phys Med Rehabil 1996;75:283–291.

10. Kirby EJ, Shereff MJ, Lewis MM. Soft-tissue tumors and tumor-likelesions of the foot: an analysis of eighty-three cases. J Bone Joint SurgAm 1989;71A:621–626.

11. Millstein SG, McCowan SA, Hunter GA. Traumatic partial foot am-putations in adults: a long-term review. J Bone Joint Surg Br 1988;70B:251–254.

12. Murari TM, Callaghan JJ, Berrey BH Jr, et al. Primary benign andmalignant osseous neoplasms of the foot. Foot Ankle 1989;10:68–80.

13. Philbin TM, Leyes M, Sferra JJ, et al. Orthotic and prosthetic devicesin partial foot amputations. Foot Ankle Clin 2001;6:215–228.

14. Roach JJ, Deutsch A, McFarlane DS. Resurrection of the amputationsof Lisfranc and Chopart for diabetic gangrene. Arch Surg 1987;122:931–934.

15. Seale KS, Lange TA, Monson D, et al. Soft tissue tumors of the footand ankle. Foot Ankle 1988;9:19–27.

16. Sundberg SB, Carlson WO, Johnson KA. Metastatic lesions of thefoot and ankle.Foot Ankle 1982;3:167–169.

17. Wetzel LH, Levine E. Soft-tissue tumors of the foot: value of MR imag-ing for specific diagnosis. AJR Am J Roentgenol 1990;155:1025–1030.

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