Living with forefoot amputation

Forefoot amputation - What next?

Most people are unprepared for a partial foot amputation. So it's natural to look for factual information on this serious topic – about the amputation itself and life afterwards.

Firstly, remember you're not helpless when part of your foot has to be amputated. You can still lead a fulfilling life after a partial foot amputation.

It's also important to remember there's a lot you can do for yourself so as to restore your mental and physical balance following a partial foot amputation. One long-term option is the fitting of a partial foot prosthesis.

This website provides information on how a partial foot prosthesis works, whether it is suitable for you and how to obtain a fitting. We also offer some tips on everyday life with your prosthesis.


Why do parts of my foot have to be amputated?

An amputation is only carried out when it's the only way to effectively protect your health in the long term. It is often necessary when the flow of blood to the affected region of the foot is no longer sufficient to supply the tissue with enough oxygen as with diabetic foot.

Another reason for an amputation are accidents resulting in injuries that make it impossible to restore the foot. Although it may sound strange, in such cases, a partial foot amputation is often the only chance to walk again.


The most common reasons

You are not alone in being affected: most of the thousands of amputations conducted each year are carried out on the foot. Diabetes or more precisely diabetic foot and serious accidents account for nine out of ten foot amputations. However, peripheral arterial occlusive disease (PAOD), better known as "smoker's leg", also plays a significant role – and is not confined to smokers.

The numbers and causes of peripheral arterial occlusive disease have remained constant for years. This is because the longer people live, the more likely they are to develop diabetes mellitus – a major risk factor in PAOD. However, since patient care continues to improve as well, the number of amputations remains about the same.


Amputation as a result of diabetic foot

Diabetic foot is the most frequent cause of foot amputations. Diabetes mellitus results in several disorders that combine with one another:

  • Reduced perspiration causes the skin on the feet to dry out and crack
  • Sugar deposits in the nerves prevent affected individuals from noticing their cracks and wounds
  • Diabetes mellitus severely impairs wound healing
  • When sores are subjected to stress, the wounds get bigger. The tissue becomes inflamed and dies
  • There is also a risk of foot inflammation since diabetes disrupts blood circulation and the cells die

Amputation in case of circulatory disorders

Smokers or those with metabolic disorders may be affected in ways similar to people with diabetes mellitus. When blood flow is disrupted, the leg no longer receives enough oxygen, leading to pain especially when walking.

One thing holds true in all cases: an amputation is only performed when certain parts of the foot cannot be saved and need to be removed so as to protect the rest of the foot or leg. It also means that there's a chance of using the foot again with the help of a partial foot prosthesis. Sometimes an amputation can be avoided by taking preventative measures well in advance.


How can I avoid an amputation due to diabetic foot?

Diabetic foot doesn't necessarily lead to an amputation. The earlier the condition is recognised, the more likely an amputation can be avoided or delayed. If you take the risks seriously and do regular checks, you can help prevent diabetic foot and a subsequent foot amputation.

  • Take good care of your feet.
  • At least once a month, check the feeling in the soles of your feet and examine the entire foot for injuries using a mirror.
  • Go for check-ups regularly and ask your doctor to examine your feet in detail. Not all family doctors are aware of the risk.
  • Buy yourself the correct shoes (not too tight, with room for the toes, and no so-called ""orthopaedic shoes""). Use orthopaedic insoles made especially for diabetics where applicable.
  • Get professional foot care (even if this is not covered by your health insurance) and let the specialist show you how to care for your own feet.
  • Use oil or urea-based creams to care for dry skin.
  • Visit a specialist when there is even the slightest sign of cracks or wounds – ideally, go to a diabetic foot clinic. Do not wait until your toe turns black or your shoe starts to smell. The first signs are dry skin, cracks, loss of feeling in the foot, calf cramps, fungus infections, calluses and warm feet.
  • If you have already been diagnosed with diabetic foot, examine your feet every day.
  • If you have diabetic foot, consult experts about special footwear modifications, protective footwear, custom footwear or orthotics to relieve the strain on the foot.
  • Have wounds treated solely by specialists for diabetes or wound healing.


What is the partial foot amputation process?

The cooperation of surgeons, internists, chiropractors, physiotherapists and orthopaedic technicians is the foundation of a successful forefoot amputation. After all, the most important thing for your future life is to be able to stand and walk with your foot as normally as possible again.

During the amputation process, the surgeon removes only as much tissue as absolutely necessary. This ensures you will be as mobile as possible afterwards. The surgeon incises the skin, removes the diseased tissue and bone, shapes the residual limb and closes the wound. The more healthy tissue is retained, the better.

The surgeon will usually only see you in the consultation prior to the operation, when the partial foot amputation process will be explained to you. The surgeon's most important task is to conduct the amputation such that you're able to do as much as possible afterwards.

Your own doctor or specialist is responsible for your care following the partial foot amputation itself. After a while, a prosthetist will become involved, who will then be responsible for making your prosthetic or orthotic device.

Today, the question isn't how, but rather precisely where the surgeon makes the cut and how the residual limb is shaped. This is because the residual limb later has to be capable of bearing weight without developing sores. To enable this, the surgeon ""pads"" the bone with muscles and leaves sufficient skin for the wound to be sutured without tension. Where possible, the scar is left on the top of the foot, so that it is not subjected to strain and chafing.

Once the amputation process is successfully completed, you can begin planning a normal life with the aid of a partial foot prosthesis.


What are the various levels of amputation?

Ideally, it'll be sufficient to amputate a toe. In any case, the surgeon will attempt to fully retain the metatarsal bones.

However, if the head of the toe joint can't be preserved, the metatarsal bone belonging to the toe must also be removed – at least partially. Medical professionals refer to this as a "ray". The loss of a ray is enough to greatly affect the ability to stand and walk. Without a prosthesis, this will lead to malpositions.

If the entire metatarsal area has already been affected, the surgeon will have to remove all of the metatarsal bones. The surgeon creates a rounded residual foot cap so that the bones are of the same length. This makes it easier for the precise fitting of a partial foot prosthesis later on.

Even when the anterior tarsal bones or the entire tarsus are affected, the surgeon should create a rounded cap so as to facilitate a prosthetic fitting.

The ankle is retained in all of these cases. As a rule, the foot will be able to bear weight with the help of a custom partial foot prosthesis – allowing you to stand and walk. If the ankle is amputated but not the knee, we call this a transtibial amputation. When the knee is also affected it is called a transfemoral amputation.

The level of amputation is usually decided by the orthopaedist and the operating surgeon. But with regard to the long-term fitting of a partial foot prosthesis, it's wise to involve the prosthetist before the amputation.


What partial foot amputation means for me?

To be perfectly honest, you're not exactly going to be at your best immediately after the amputation. You'll have incurred a loss and your self-confidence may have suffered. But you must learn to cope with how your body now feels.

Standing and walking will seem difficult at first. This is because the supporting surface of your foot will have changed after the partial foot amputation and your legs are of different length. You're missing part of the leverage you need for walking. You'll also naturally tread more lightly on the amputated side, as a precaution, and this compensating behaviour is likely to lead to malpositions. That's why it's all the more important to find out about prosthetic devices early on, as this will help you resume your accustomed way of moving.

If you're embarrassed and find it hard to appear in public after your amputation, you'll also discover a prosthesis can help you overcome your anxieties. A partial foot prosthesis offers you freedom of movement in your ankle, so that your movements appear almost completely natural.


What happens in the weeks immediately following the amputation?

The way back to normal life begins immediately after the partial foot amputation. The first few weeks are crucial in determining how well you'll live with the amputation later on. To ensure you'll soon be able to walk, ride a bike or drive a car again, the wound must heal and the muscles have to be built up again. This requires strength and patience.

After the amputation, you'll need bed rest for a few days and cannot put any weight on the foot at all. Fortunately, there'll be all the helpers you need at your bedside to support you. Nobody can say in advance how long you'll have to stay in bed, or how long it will take for the wound to heal and when you can walk, drive a car, ride a bike or go to work again. But one thing is for certain: the more active and positive you are, the faster your rehabilitation will progress.

All efforts initially focus on healing the wound. But even during this stage, a physiotherapist will perform mobility exercises with you in order to ensure that your muscles do not wither and that the joints remain mobile despite the long period of inactivity. Later the physiotherapist will practice alternative movements and train your residual limb muscles so that you can confidently walk with a prosthesis.

Rehabilitation: practice makes perfect

Equally importantly, the physiotherapist will need to train your perception of the residual limb. This is so new that your brain is unable to process the messages from the nerves at first. But feeling your foot very accurately is of crucial importance for your health – and for the subsequent fitting of a prothesis or orthopaedic device.

As soon as the wound is fully healed and you're able to support your weight on the residual limb, you'll be fitted with a prosthesis. This is something you should gradually get used to.

You'll probably be provided with a special partial foot relief shoe for this transitional period. You can walk in this shoe without overburdening the wound. This is also the time for occupational therapy. The occupational therapist will help you develop your dexterity and will practice everyday and work-related movements with you. With your therapist's support, you'll regain control of your life day by day.

Incidentally, participating in gait training and consultations with an occupational trainer, psychologists and, where applicable, family assistants are also part of the rehabilitation process. As is examining your past lifestyle: Do you have a healthy diet? Are you a smoker? Do you drink too much alcohol or take unnecessary medication?

No matter how important all the experts are, your active participation plays a larger role in your rehabilitation.


What do I need to know about healing wounds?

After the partial foot amputation, you'll have to stay in bed at first and keep the foot elevated so that blood can easily flow back to the heart. Blood and lymph accumulate in the wound as a result of the operation and must be gradually resorbed.

An elastic bandage promotes this resorption of fluid. It can apply even pressure without pulling on the wound. Every day, your bandage is changed and the wound is examined for inflammation and congestion. The bandages have another important job: they shape the residual limb so that it will later be capable of bearing weight.

Nor should you forget that a partial foot amputation is a major operation, resulting in a serious wound. It can take weeks or even months for it to heal completely. The healing process may not progress smoothly; in fact, complications are not unusual among diabetic patients. Diabetic foot, the reason for amputation among diabetics, simultaneously impairs wound healing. Time is the most crucial factor in this phase.


What prostheses and other fitting options are available?

A customised, moulded insole may be sufficient after a minor amputation. An insole cannot restore lost functionality, but stabilising the foot-bed might suffice after very minor surgery.

Custom-made by a prosthetist, a silicone partial foot prosthesis allows you to move your ankle completely freely while fitting your residual foot ""like a glove"". As a result, your whole movement appears more natural. Current studies also indicate that the muscles are more active compared to other fittings. Thanks to the flexible material, you can also walk longer distances and wear conventional shoes. In other words, you won't attract any attention by the way you walk.

While some doctors and prosthetists may recommend a custom shoe from an orthopaedic shoemaker, this is not necessarily the best option for you. Not only is it conspicuous, it may also lead to subsequent problems because your ankle is immobilised. Walking in these shoes does not appear smooth and you may find them uncomfortable.

An orthopaedic inner shoe, also made by an orthopaedic shoemaker, is less conspicuous. However, here, too, the upper ankle is immobilised, so you can't wear it with standard footwear bought from a shoe store.

The Bellmann prosthesis supplied by a prosthetist offers significantly more mobility. With the help of a stocking, you slip into a prosthesis made of several layers of foam, which does not cover the upper ankle. Other advantages are its low weight and a shape that lets you wear conventional shoes. However, the look of the Bellmann prosthesis cannot be adapted to match your other foot, so it still stands out as a prosthesis. The material also wears out comparatively quickly, meaning you need a new one after two years. Finally, the stocking causes friction which you may find unpleasant.


Treatment experts on site


Frequently asked questions about the partial foot prosthesis

What is a partial foot prosthesis?

Your new partial foot prosthesis restores the function and appearance of the amputated parts of your foot. It supports your everyday movements, boosts muscle activity, improves the return flow of blood in the leg and restores a virtually normal foot appearance.

In terms of looks, the partial foot prosthesis can replicate your healthy foot down to the finest detail. This is why Ottobock offers three different versions of prosthesis. In the Basic version, the hue is matched to your own skin colour, such that anyone not in the know will hardly notice the amputation.

What is a partial foot prosthesis made of?

Ottobock uses high-quality medical grade silicone (HTV silicone) in its partial foot prostheses. The major advantage of this high-quality silicone is that its rigidity and hardness can be varied on different parts of the foot. This means all the various parts of your prosthesis can fulfil their precise functions: firm where your foot rolls over, softer where your residual limb takes the strain.

The silicone used in your prosthesis is also highly skin-friendly: since it is gas and vapour-permeable, it allows perspiration to dissipate. It doesn't contain softening agents (which are now suspected of being harmful to health), doesn't become porous and is odourless. In fact, the material is usually perceived as pleasant on the skin.


Is a partial foot prosthesis suitable for me?

The fitting and subsequent wearing of a partial foot prosthesis only makes sense once the following criteria are met:

  • Your amputation wound is fully healed
  • Your ankle joint is capable of bearing weight
  • Your residual limb volume is stable and it's able to bear your weight

With the partial foot amputations mentioned above, this is usually the case after only a few weeks. Then you'll be ready for a silicone prosthesis, which nowadays can be used with almost all partial foot amputations.

A prosthetic option has to be ruled out only if your residual limb is subject to pronounced swelling. This is because it cannot be optimally fitted and would exert pressure on the residual foot. Fortunately, this is a rare exception.


How well will I be able to walk with a partial foot prosthesis?

A partial foot prosthesis is such a good replacement for the amputated parts of the foot because it restores the full surface for your treading and rollover. This gives you confidence while walking. Because the prosthesis remains flexible as you walk, you can move your whole body correctly. Rather than assuming a corrective, relieving posture, the load on your musculature is entirely natural. This works so well that you can even walk barefoot with the prosthesis. Furthermore, half of all partial foot prosthesis users were able to walk distances of five kilometres or more.

How do I care for a partial foot prosthesis?

You can keep your partial foot prosthesis on when you shower, but the best way to clean it is in the sink using lukewarm soap and water. If you wash your silicone prosthesis daily, it can last up to five years. Should you get a stubborn stain on your partial foot prosthesis, simply boil it for a few minutes in tap water.

No solvents or other chemicals are needed when caring for your partial foot prosthesis. In fact, solvents must not be used, as they not only permeate the silicone but are also transfered to the skin when you wear the prosthesis.


How can I obtain a partial foot prosthesis?

You should first talk to your doctor about the possibility of a partial foot prosthesis. If you have health insurance, you'll need a prescription to be fitted for a prosthesis in a medical supply company. Health insurers normally cover the cost of a purely functional model, and you'll be expected to pay for any cosmetic features, such as different skin colours.

Your next step is to find a medical supply company that has a great deal of experience with partial foot prostheses. Ottobock is not only a trusted supplier of prosthetics, but also works with certified partners who have the required equipment, technology and special training to ensure an optimum fitting.

Once you've decided on a prosthesis, you'll have a second appointment where the prosthetist will precisely measure your foot, take photos and prepare a plaster cast. These data will be used to make a trial prosthesis for you to wear for at least four weeks. This trial period allows the prosthetist to adapt the prosthesis as needed. If for no other reason, this is necessary because your muscles gain strength through exercise as the prosthesis allows you to walk again. The trial prosthesis is used to test the exact fit to your residual limb, so that your prosthesis will be comfortable to wear in the long term.

Based on your experience with the trial prosthesis, the final prosthesis will be made. Taking into consideration all the information and corrections gathered over the trial period, you'll soon receive your own, customised partial foot prosthesis that allows you to lead a virtually normal life.



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