Limb salvage surgery: operations that save the foot

What limb salvage surgery is

Limb salvage surgery means operating on the foot to keep it: stopping infection, helping a stubborn wound close, or correcting a shape that keeps breaking down. We often call it limb preservation.

A published classification ranks diabetic foot surgery from elective, through prophylactic (preventing an ulcer) and curative (healing a wound), to emergency surgery for infection.⁠^[1] In a study of 180 people with diabetes, the risks of a new ulcer, infection and amputation rose along that scale, from elective to emergency.⁠^[7] That’s one reason we look early for problems a smaller, planned operation can fix.

Surgery builds on wound care: offloading, cleaning the wound, treating infection and good blood flow stay the foundation, and many wounds heal with that care alone. See wound care visits.

The surgical toolbox

Dr. Ozturk performs each of these operations for the feet that need them.

Draining infection. Timing matters: in 106 people with diabetes and a deep foot abscess, the longer surgery was delayed, the higher the eventual amputation tended to be.⁠^[3] In a review of 112 people treated in hospital for a diabetic foot infection, prompt surgery was linked with fewer amputations above the ankle (13%, against 27.6% with no surgery in the first three hospital days) and hospital stays at least six days shorter.⁠^[2] See surgery for diabetic foot infection.

Removing infected bone. After surgery to clean out infected bone (osteomyelitis), a shorter antibiotic course may be enough: in a small randomized trial of 93 people with diabetes, three weeks of antibiotics did about as well as six.⁠^[8] Dr. Ozturk also takes bone biopsies when needed, so the lab can identify the germ and guide antibiotics.⁠^[9] See surgery for bone infection.

Taking the pressure off. When offloading hasn’t healed an ulcer under the forefoot, the offloading guideline suggests considering an operation that unloads it: lengthening the Achilles tendon, removing the metatarsal head beneath the ulcer, reshaping the joint, or cutting and realigning the metatarsal. For an ulcer on the tip or underside of a flexible hammertoe or claw toe in a numb foot, it recommends a small cut that releases the tendon curling the toe down.⁠^[4] See surgery that takes pressure off ulcers and removing bony prominences.

Rebuilding a collapsed foot. When a Charcot foot collapses and ulcerates, Dr. Ozturk may shave off the bony prominence under the ulcer, or realign and fuse the foot with internal hardware or an external frame. In a systematic review of reconstructed feet, the bones fused in 86%, 5.5% later needed amputation, and 36% of people had complications tied to the technique used.⁠^[5] See Charcot reconstruction and external fixation.

Closing the wound. A clean wound with good blood flow can be closed with a skin graft or local flap, and for the wounds that need it we use negative-pressure wound therapy (a wound VAC). In a randomized trial of 162 people with diabetes and a partial foot amputation wound, 56% healed within 16 weeks with negative-pressure therapy, against 39% with standard moist dressings.⁠^[10] When hyperbaric oxygen therapy could help, we refer you for it. See skin grafts and flaps and negative-pressure wound therapy.

Choosing the least surgery that keeps you walking

Our aim is the smallest operation that heals the foot and keeps you walking. When tissue can’t be saved, such as a toe lost to gangrene (see dark, black or blue toes), we remove only what is lost, at the lowest level that will heal: a toe, a toe with its metatarsal (a ray), the front of the foot (transmetatarsal) or part of the midfoot. When a foot needs one, Dr. Ozturk performs these partial foot amputations himself.

Length matters. In a classic study of 70 people with an amputation above the knee, below the knee or at the ankle, walking, judged by gait and its energy cost, was better the lower the amputation, and the authors advised the lowest possible level when function is the main concern.⁠^[11] A well-planned partial foot amputation is itself limb salvage.

In a review of 24 studies, about 1 in 4 transmetatarsal amputations was followed by another operation, and the authors suggested that the choice between this and a smaller amputation may depend on each person’s circumstances.⁠^[12] If a below-knee amputation were ever needed, a vascular or orthopedic surgeon would perform it. See toe and partial foot amputation and, if amputation has been recommended, a limb salvage second opinion. For nerve pain afterward, see the Nerve Institute’s page on pain after leg amputation (external site).

Blood flow and teamwork

About half of people with diabetes and a foot ulcer have peripheral artery disease, and vascular guidelines set out who should be prioritized for a procedure to restore blood flow.⁠^[13] We check circulation with noninvasive testing at our practice; if it’s reduced, we refer you to a vascular specialist and plan your surgery around their treatment. See restoring blood flow.

We also coordinate with your primary care doctor or endocrinologist on blood sugar.

Dr. Efe Ozturk is a Foot and Ankle Surgeon who is also board certified in wound care (FAPWH) and podiatric medicine (DABPM), so the same physician plans your wound care and your surgery.

Why early care matters

A foot ulcer is a signal to look after your whole health, not only your foot. Researchers who pooled studies published after 2007 found that about 3 in 10 people with a diabetic foot ulcer had died within five years, and the share was higher after an amputation.⁠^[14] The authors call for prevention, and for care that keeps healed ulcers from coming back, to add ulcer-free, hospital-free and active days.⁠^[14] That is our aim too. See keeping your foot in remission.

Preparing and recovering

In a study of 2,060 foot and ankle operations, nerve damage and an A1c of 8% or higher were each linked to infection of the surgical wound.⁠^[15] Before planned surgery we work with you and your other doctors on blood sugar, smoking and clearing infection; read why smoking and diabetes slow surgical healing (external site). Recovery usually means time off your feet, regular wound checks and, once healed, protective shoes or inserts. See preparing for limb salvage surgery and recovery.

Risks and limits

Wound infection is a key risk: in that study, infection followed 3.1% of operations, but people with at least one diabetes complication had 7.25 times the risk of people without diabetes or nerve damage.⁠^[15] Further surgery is sometimes needed. When the foot’s shape changes, pressure can build in a new spot, so we keep checking; see problems after partial foot amputation. Any operation also carries anesthesia and blood-clot risks. Not every foot can be saved; when that is the case, we explain why and help you plan the next step.

Questions to ask

• Is this operation meant to stop infection, heal the wound or prevent the next ulcer?
• Is my blood flow good enough to heal?
• Is there a smaller operation that would do the job?
• How long will I keep weight off the foot?
• What shoes or inserts will keep the foot healed?

When to seek care

See us within a day or two for any foot wound that isn’t healing, especially if you have diabetes. If you have diabetes or poor circulation, call us the same day for signs of infection, such as a red, hot, swollen foot or new drainage, or for new foot pain at night or at rest.