Depression and anxiety symptoms are underestimated risk factors for postoperative prognosis in patients with Type 2 diabetes and peripheral artery disease undergoing partial foot amputation: Results from a prospective cohort study.

OBJECTIVE: The aim of this study was to evaluate the prevalence and impact of depression and anxiety symptoms on post-operative prognosis and 1-year all-cause mortality in a large unique cohort of patients with Type 2 diabetes (T2D) and peripheral artery disease (PAD) after partial foot amputation (PFA). METHODS: Prospective cohort study with 1-year follow-up of 785 consecutive patients (mean age 60.9 ± 9.1 years; 64.1% males) with T2D and PAD after PFA. Depressive symptoms were assessed by Patient Health Questionnaire-9 (PHQ-9) and anxiety symptoms by Hamilton Anxiety Rating Scale (HARS). We used multivariable Cox proportional hazard models to examine the association of depression and anxiety with all-cause mortality. RESULTS: One-year all-cause mortality was 16.9% (n = 133). 331 (42.1%) patients had PHQ-9 score ≥ 10 indicating major depressive disorder. After adjusting for confounders, PHQ-9 score ≥ 10 was associated with an increased risk of 1-year all-cause mortality (HR = 1.68 (95%CI[1.16-2.44], p = 0.006). Depression dimensions of negative self-feeling and suicidal ideations were independently associated with 1-year mortality (HR = 1.26 (95%CI[1.24-1.55], p = 0.029 and HR = 2.37 (95%CI[1.89-2.96], p < 0.001, respectively). Compared to no depression, severe depressive symptoms (cut-off≥20) were associated with increased all-cause mortality (HR = 3.9 (95%CI [1.48-10.29], p = 0.006). Compared to no anxiety, severe anxiety symptoms (cut-off>30) were associated with increased 1-year mortality (HR = 2.25(95%CI [1.26-4.05], p = 0.006). CONCLUSION: Depressive symptoms and severe anxiety have shown independently increased risk of 1-year all-cause mortality in patients with T2D and PAD requiring PFA. Our results indicate that screening for anxiety and depression should be considered under these circumstances to identify patients at increased risk to allow appropriate intervention.

Morbidity and Mortality of the Transmetatarsal Amputation: A Comparative NSQIP Analysis.

The objective of this investigation was to compare the morbidity and mortality of transmetatarsal amputation to other frequently performed surgical procedures utilizing a large US database. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was interrogated for the purposes of this investigation. We initially extracted data related to the Current Procedural Terminology (CPT) code 28805 (amputation, foot; transmetatarsal) and the variable labels "estimated probability of morbidity" and "estimated probability of mortality." We subsequently performed a CPT code search for those procedures occurring at a frequency greater than 10,000 in the database, and additionally extracted data for estimated probability of morbidity and estimated probability of mortality for these procedures. This resulted in identification of 17 additional procedures. CPT code 28805 was associated with the highest estimated probability of morbidity of the cohort (0.1360 ± 0.0669), and this demonstrated statistical significance higher than all other CPT codes (p < .001). CPT code 28805 was associated with the second-highest estimated probability of mortality of the cohort (0.0327 ± 0.0596). This demonstrated statistical significance less than that of CPT code 27245 (0.0327 ± 0.0596 vs 0.0547 ± 0.0661; p < .0001), but statistical significance higher than all other CPT codes (p<0.001). The results of this investigation indicate that transmetatarsal amputation carries a substantial risk for morbidity and mortality in comparison to other commonly performed surgical procedures.

Effect of Partial Foot Amputation Level on Gait Independence in Patients With Chronic Lower Extremity Wounds: A Retrospective Analysis of a Japanese Multicenter Database.

Partial foot amputation (PFA) is generally planned to minimize the amputation level; nonetheless, the effect of PFA levels on gait independence in amputees remains unclear. This study aimed to investigate the impact of PFA levels of the forefoot on gait independence in patients with chronic lower extremity (LE) wounds. This multicenter retrospective cohort study included 232 hospitalized Japanese patients treated and rehabilitated for chronic LE wounds. A multivariate analysis based on PFA levels was conducted for gait independence at discharge, with age and comorbidities as independent variables. Patients with Lisfranc amputation had significantly less independent gait than patients with more distal amputation and those without amputation (<22% vs >40%; P = .027; Fisher's exact test). Logistic regression analysis revealed that Lisfranc amputation (odds ratio [OR]: 0.257, P = .047), age (OR: 0.559, P = .043), and chronic limb-threatening ischemia (OR: 0.450, P = .010) were independent factors associated with gait independence. Additionally, the regression model confirmed discrimination performance using the C index (0.691, P < .001) with receiver operating characteristic analysis. In patients with chronic LE wounds undergoing PFA, Lisfranc amputation was negatively associated with gait independence.

Pathological gait in partial foot amputation versus peripheral neuropathy.

Partial foot amputation (PFA) is a common surgical loss of part of either the forefoot or mid-foot. It is usually the sequel to a cascade of physiological foot dysfunction such as peripheral neuropathy (PN). The gait compensation mechanisms associated with these foot disorders aren't well understood yet. PURPOSE: The aim of the study was to evaluate pathological gait compensation mechanisms in PFA due to PN versus PN alone through a comprehensive gait analysis. METHODS: Plantar pressure, GRF, load distribution, footprint length and area, foot progression angle, step length, percentage of double limb support, and stance time were measured on 53 participants assigned into two well-matched groups: (A) 25 subjects with healed unilateral PFA and (B) 28 subjects with PN without ulcer. The gait analysis was conducted at a self-preferred walking speed using the FREEMED baropodometric platform and FREESTEP software. RESULTS: The PFA group showed a significant decrease in load over the remaining toes and metatarsal heads compared to the PN group (p = .001 and p = .003, respectively). Conversely, the PFA group showed a significant increase in load over the mid-foot and peak plantar pressure during mid-stance (p = .007 and p = .016, respectively). All other measured variables showed no significant difference between the two groups (p > .05). CONCLUSION: Individuals with PFA and PN or PN alone tend to shift their body loads posteriorly and redistribute their loads to compensate for the insufficient support from the forefoot. The PFA group was worse than the PN group. Furthermore, the PFA may not be the primary cause of the altered gait but rather the underlying systemic disease. The PFA surgery only worsens the compensatory mechanism.

Coronary artery calcium score and coronary computed tomography angiography predict one-year mortality in patients with type 2 diabetes and peripheral artery disease undergoing partial foot amputation.

METHODS: This is a single-center prospective cohort study including 199 consecutive patients with T2D, PAD (mean age 62.3 ± 7.2 years; 62.8% males), and preoperative CACS and CCTA undergoing PFA and followed-up over 1 year. RESULTS: Over a period of 1 year follow-up, a total of 35 (17.6%) participants died. The area under ROC curve to predict mortality for the CACS was 0.835 (95% CI:0.769-0.900), for CCTA 0.858 (95% CI:0.788-0.927). After adjustment for confounders, compared to no-stenosis on CCTA (reference), the risk of all-cause mortality in non-obstructive coronary atery disease (CAD) increased (HR = 1.38, 95% CI [0.75-12.86], p = .284), 1-vessel obstructive CAD (HR = 8.13, 95% CI [0.87-75.88], p = .066), 2-vessels (HR = 10.94, 95% CI [1.03-115.8], p = .047), and 3-vessels (HR = 45.73, 95% CI [4.6-454.7], p = .001) respectively. Increasing levels of CACS tended to be associated with increased risk of all-cause mortality (HR = 1.002, 95% CI [1.0-1.003], p = .061). 61/95 patients with obstructive CAD underwent coronary revascularization. CONCLUSIONS: Coronary artery calcium score and CCTA have a high predictive value for 1-year all-cause mortality in T2D patients undergoing minor amputations and may be considered for preoperative risk assessment allowing timely preventive interventions.

Associations between partial foot amputation level, gait parameters, and minimum impairment criteria in para-sport: A research study protocol.

Altered biomechanics due to amputation can contribute to substantial limitations, influencing sporting activities. Individuals with lower extremity amputations or congenital lower limb deficiency are encouraged to participate in para-sports. However, to compete in Paralympic sports, the candidate must have an impairment that results in lower extremity loss of function and meets or exceeds the sport's minimum impairment criteria (MIC). This review will focus on the MIC for competitive wheelchair tennis. Limb deficiency is known as one of the MIC used to regulate participation in competitive para-sports since it impacts gait, kinematics, and biomechanics of both the upper and lower body. Notwithstanding, it is questionable whether the MIC concerning limb deficiency is set at the correct level for determining eligibility for participating in Paralympic sports. This study aims to provide an overview of the evidence examining the impact of different partial foot amputation (PFA) levels on gait as a proxy for sporting performance. This scoping review will be based on a 6-step methodological framework and Preferred Reporting Items for Systematic Reviews and Meta-Analysis, extension for scoping reviews (PRISMA-ScR). Studies will be selected from PubMed, Embase, CINAHL, and SPORTDiscus. Two authors will screen the titles/abstracts independently. Selected studies will be scrutinised, and the same authors will extract data. Findings will be relevant to informing the evidence-based development of MIC for lower limb impairment after PFA and may be extrapolated to specific Paralympic sports, including wheelchair tennis. Results will be disseminated through scientific publications and conferences to audiences interested in Paralympic sports.

The Effect of Remnant Metatarsal Parabola Structure on Transmetatarsal Amputation Primary Healing and Durability.

Although generally considered to be both a durable and functional procedure for limb preservation, the transmetatarsal amputation (TMA) has high rates of complication, failure, revisional operation, and progression to more proximal amputation. The objective of this investigation was to determine the effect of remnant metatarsal parabola structure on healing outcomes following TMA. A retrospective chart review was performed of subjects undergoing a complete TMA with primary closure. We considered 4 patterns of remnant metatarsal parabola structure. TMA pattern type 1 was a normal parabola with the remnant second metatarsal extending furthest distally and slightly longer than the remnant first and third metatarsals with a gradual lateral taper. TMA pattern type 2 was the first metatarsal remnant extending furthest distally with a gradual lateral taper. TMA pattern type 3 was a relatively long fifth metatarsal remnant without the presence of a gradual lateral taper. And TMA pattern type 4 was a relatively short first metatarsal remnant with a relatively long second metatarsal with a gradual lateral taper. Seventy-three transmetatarsal amputations in 73 subjects met selection criteria. Thirty-nine (53.4%) amputations healed primarily at 90 days. No statistically significant differences were observed between groups with respect to the 90-day primary healing rate (p = .571) or 1-year ambulation rate without wound recurrence or reoperation (p = .811). These results might indicate that the remnant metatarsal structure does not have an effect on transmetatarsal amputation outcome. It is our hope that these results add to the body of knowledge and lead to further investigations into outcomes of limb preservation surgical interventions.

Association between the level of partial foot amputation and gait: a scoping review with implications for the minimum impairment criteria for wheelchair tennis.

OBJECTIVE: This scoping review examines how different levels and types of partial foot amputation affect gait and explores how these findings may affect the minimal impairment criteria for wheelchair tennis. METHODS: Four databases (PubMed, Embase, CINAHL and SPORTDiscus) were systematically searched in February 2021 for terms related to partial foot amputation and ambulation. The search was updated in February 2022. All study designs investigating gait-related outcomes in individuals with partial foot amputation were included and independently screened by two reviewers based on Arksey and O'Malley's methodological framework and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. RESULTS: Twenty-nine publications with data from 252 participants with partial foot amputation in 25 studies were analysed. Toe amputations were associated with minor gait abnormalities, and great toe amputations caused loss of push-off in a forward and lateral direction. Metatarsophalangeal amputations were associated with loss of stability and decreased gait speed. Ray amputations were associated with decreased gait speed and reduced lower extremity range of motion. Transmetatarsal amputations and more proximal amputations were associated with abnormal gait, substantial loss of power generation across the ankle and impaired mobility. CONCLUSIONS: Partial foot amputation was associated with various gait changes, depending on the type of amputation. Different levels and types of foot amputation are likely to affect tennis performance. We recommend including first ray, transmetatarsal, Chopart and Lisfranc amputations in the minimum impairment criteria, excluding toe amputations (digits two to five), and we are unsure whether to include or exclude great toe, ray (two to five) and metatarsophalangeal amputations. TRIAL REGISTRATION: The protocol of this scoping review was previously registered at the Open Science Framework Registry (https://osf.io/8gh9y) and published.

Soft Tissue Reconstruction with Diabetic Foot Tissue Loss.

Although substantial advances have been made in treatment of diabetic foot disease with respect to patient education, preventative measures, early intervention, and prophylactic procedures, most surgical interventions for this condition are reactionary. Patients still primarily present to emergency departments with acute infections and tissue necrosis. The surgical intervention for this results in soft tissue deficit, often with partial foot amputation, through excisional debridement of pathologic tissue. Minimizing this initial soft tissue loss, with subsequent reconstruction of the defect, forms the focus of this article with a detailed anatomic assessment of structures at risk in the forefoot, midfoot and rearfoot.

Vacuum-assisted closure versus moist dressings in the treatment of diabetic wound ulcers after partial foot amputation: A retrospective analysis in 65 patients.

PURPOSE: Changes in weight-bearing patterns after partial foot amputations may lead to new localized high-pressure points and keratosis due to ulcerations in patients with neuropathies and hypovascular limbs. As a result, diabetic foot ulcers (DFUs) after partial foot amputations are very complex. The aim of this study was to compare the effectiveness of vacuum-assisted closure (VAC) therapy with conventional moist wound dressings in the treatment of diabetic wound ulcers after partial foot amputations. METHODS: Sixty-five diabetic patients with a DFU, who had previously undergone partial foot amputation surgery, were assigned to treatment with VAC (group A: 31 patients) or conventional wound moist dressing (group B: 34 patients). The final results were considered as failed treatment if reamputation was required. Conversely, reaching 90% of wound granulation was considered to be a successful endpoint. RESULTS: The average time to reach 90% granulation tissue was significantly lower in group A (7.8 ± 1.2 weeks vs. 11.1 ± 1.2 weeks; p < 0.001). However, there was no significant difference regarding the reamputation requirements; 38.7% (12 patients) in group A and 41.2% (14 patients) in group B, ( p = 0.839). CONCLUSION: The results of this study allowed us to conclude that VAC therapy system appears to be an effective treatment for patients with complex DFUs who had previously undergone partial foot amputation.

Anatomic Limitations of the Transmetatarsal Amputation With Consideration of the Deep Plantar Perforating Branch of the Dorsalis Pedis Artery.

The transmetatarsal amputation is considered a durable procedure with respect to limb salvage when managing the consequences of diabetic foot disease. The success of the procedure is, in part, determined by the preoperative appreciation of arterial and functional status. The objectives of the present investigation were to determine the length of the remaining first metatarsal required during transmetatarsal amputation to preserve the anastomotic connection of the deep plantar perforating artery and subsequent "vascular arch" of the foot and the insertion of the tibialis anterior tendon. The primary outcome measure of our investigation was a measurement of the distance between the first metatarsal-medial cuneiform articulation and the distal extent of the deep plantar perforating artery in 85 embalmed lower limbs. As a secondary outcome measure, the insertion of the tibialis anterior tendon was evaluated relative to the deep plantar perforating artery. The most distal extent of the deep plantar perforating artery was observed at a mean ± standard deviation of 15.62 ± 3.74 (range 6.0 to 28.28) mm from the first metatarsal-medial cuneiform articulation. Most (89.41%) of the arteries were found within 20 mm of the first metatarsal-medial cuneiform articulation. The insertion of the tibialis anterior tendon was found to be proximal to the deep plantar perforating artery in all specimens (100.0%). In conclusion, 2.0 cm of remnant first metatarsal might represent an anatomic definition of how "short" a transmetatarsal amputation can safely be performed in most patients when considering the vascular and biomechanical anatomy.

Parametric study of orthopedic insole of valgus foot on partial foot amputation.

Orthopedic insole was important for partial foot amputation (PFA) to achieve foot balance and avoid foot deformity. The inapposite insole orthosis was thought to be one of the risk factors of reamputation for foot valgus patient, but biomechanical effects of internal tissues on valgus foot had not been clearly addressed. In this study, plantar pressure on heel and metatarsal regions of PFA was measured using F-Scan. The three-dimensional finite element (FE) model of partial foot evaluated different medial wedge angles (MWAs) (0.0°-10.0°) of orthopedic insole on valgus foot. The effect of orthopedic insole on the internal bone stress, the medial ligament tension of ankle, plantar fascia tension, and plantar pressure was investigated. Plantar pressure on medial heel region was about 2.5 times higher than that of lateral region based on the F-Scan measurements. FE-predicted results showed that the tension of medial ankle ligaments was the lowest, and the plantar pressure was redistributed around the heel, the first metatarsal, and the lateral longitudinal arch regions when MWA of orthopedic insole ranged from 7.5° to 8.0°. The plantar fascias maintained about 3.5% of the total load bearing on foot. However, the internal stresses from foot bones increased. The simulation in this study would provide the suggestion of guiding optimal design of orthopedic insole and therapeutic planning to pedorthist.

Biomechanical analysis of suture locations of the distal plantar fascia in partial foot.

PURPOSE: The aim of this study was to evaluate the rationality of the suture locations of distal plantar fascia (DPF) after foot amputation to avoid the risk factors of re-amputation or plantar fasciitis. METHODS: The tensile strain of plantar fascia (PF) in the different regions was measured by uni-axial tensile experiment. A three-dimensional (3D) finite element model was also developed to simulate tensile behaviour of PF in weight bearing conditions. The model includes 12 bones, ligaments, PF, cartilage and soft tissues. Four suture location models for the DPF were considered: the fourth and fifth DPF were sutured on the third metatarsal, the cuboid, and both the third metatarsal and the cuboid, and one un-sutured model. RESULTS: The peak tensile strain of the first, second and third PF was 0.134, 0.128 and 0.138 based on the mechanical test, respectively. The fourth and fifth DPF sutured at the cuboid and the third metatarsal could offer more favourable outcomes. The peak strain of 4.859 × 10(-2), 2.347 × 10(-2) and 1.364 × 10(-2) in the first, second and third PF showed the least outcomes in stance phase. Also, peak strain and stress of the residual PF reduced to 4.859 × 10(-2) and 1.834 MPa, respectively. The stress region was redistributed on the mid-shaft of the first and third PF and the peak stress of medial cuneiform bone evidently decreased. CONCLUSIONS: The fourth and fifth DPF suture at the third metatarsal and cuboid was appropriate for the partial foot. The findings are expected to suggest optimal surgical plan of the DPF suture and guide further therapeutic planning of partial foot patients.

Lower-limb amputation and body weight changes in men.

Little is known about the relationship between lower-limb amputation (LLA) and subsequent changes in body weight. We conducted a retrospective cohort study using clinical and administrative databases to identify and follow weight changes in 759 males with amputation (partial foot amputation [PFA], n = 396; transtibial amputation [TTA], n = 267; and transfemoral amputation [TFA], n = 96) and 3,790 nondisabled persons frequency-matched (5:1) on age, body mass index, diabetes, and calendar year from eight Department of Veterans Affairs medical care facilities in the Pacific Northwest. We estimated and compared longitudinal percent weight change from baseline during up to 39 mo of follow-up in participants with and without amputation. Weight gain in the 2 yr after amputation was significantly more in men with an amputation than without, and in men with a TTA or TFA (8%-9% increase) than in men with a PFA (3%-6% increase). Generally, percent weight gain peaked at 2 yr and was followed by some weight loss in the third year. These findings indicate that LLA is often followed by clinically important weight gain. Future studies are needed to better understand the reasons for weight gain and to identify intervention strategies to prevent excess weight gain and the deleterious consequences that may ensue.

Physical activity barriers and enablers in older Veterans with lower-limb amputation.

Little is known about the types of physical activities that older individuals with lower-limb loss perform, correlates of regular physical activity (PA), and barriers and facilitators to PA. We conducted an exploratory study in 158 older Veterans from the Pacific Northwest with a partial foot (35%), below-knee (39%) and above-knee (26%) amputation. Ninety-eight percent of survey respondents were male, on average 65 yr of age and 15 yr postamputation; 36% of amputations were trauma-related. The most commonly reported physical activities were muscle strengthening (42%), yard work and/or gardening (30%), and bicycling (11%). Forty-three percent were classified as physically active based on weekly moderate- and vigorous-intensity PA. History of vigorous preamputation PA was positively associated with being active, while low wealth and watching ≥5 h/d of television/videos were inversely associated. While pain- and resource-related barriers to PA were most frequently reported, only knowledge-related and interest/motivation-related barriers were inversely associated with being active. Family support and financial assistance to join a gym were the most commonly reported factors that would facilitate PA. To increase PA in the older amputee population, interventions should address motivational issues, knowledge gaps, and television watching; reduce financial barriers to exercising; and consider involving family members.

Technical tip: percutaneous bone shaving and ulcer endoscopy to manage abnormal pressure point of the sole.

Abnormal plantar pressure can follow post-traumatic foot deformity, Charcot neuroarthropathy and partial foot amputations. Surgery is indicated if the condition does not improve with orthotic treatment. We describe the techniques of percutaneous shaving of the plantar bone prominence and ulcer endoscopy to manage abnormal pressure points under the sole of the foot.

Partial foot amputations for salvage of the diabetic lower extremity.

Lower extremity infections are a common yet unfortunate complication of diabetes-related ulcers often requiring surgical intervention. The main goals of surgical treatment consist of selecting the appropriate procedure to effectively eradicate nonsalvageable tissue, achieve primary healing, and maximize subsequent dynamic functionality. An overview of each partial foot amputation procedure is discussed with a focus on procedure selection as well as standard and advanced surgical techniques. The effective application of partial foot amputations in the high-risk diabetic population can act to minimize the need for major proximal lower limb amputations.

Incidence of lower limb amputation in Australian hospitals from 2000 to 2010.

BACKGROUND: Contemporary literature reports that the incidence of lower limb amputation has declined in many countries. This impression may be misleading given that many publications only describe the incidence of lower limb amputations above the ankle and fail to include lower limb amputations below the ankle. OBJECTIVES: To describe trends in the incidence of different levels of lower limb amputation in Australian hospitals over a 10-year period. STUDY DESIGN: Descriptive. METHOD: Data describing the age-standardised incidence of lower limb amputation were calculated from the Australian National Hospital Morbidity database and analysed for trends over a 10-year period. RESULTS: The age-standardised incidence of lower limb amputation remained unchanged over time (p = 0.786). A significant increase in the incidence of partial foot amputations (p = 0.001) and a decline in the incidence of transfemoral (p = 0.00) and transtibial amputations (p = 0.00) were observed. There are now three lower limb amputations below the ankle for every lower limb amputation above the ankle. CONCLUSION: While the age-standardised incidence of all lower limb amputation has not changed, a shift in the proportion of lower limb amputations above the ankle and lower limb amputations below the ankle may be the result of improved management of precursor disease that makes partial foot amputation a more commonly utilised alternative to lower limb amputations above the ankle. Clinical relevance This article highlights that although the incidence of lower limb amputation has remained steady, the proportion of amputations above the ankle and below the ankle has changed dramatically over the last decade. This has implications for how we judge the success of efforts to reduce the incidence of lower limb amputation and the services required to meet the increasing proportion of persons with amputation below the ankle.

Deliberations about the functional benefits and complications of partial foot amputation: do we pay heed to the purported benefits at the expense of minimizing complications?

While discussion about the benefits and complications of partial foot amputation (PFA) is not new, much of it has hinged on anecdotal evidence and led to the popular view that the risk of complications and secondary amputation is reasonable when weighed against the perceived benefits associated with maintaining the ankle joint and residual foot length, including more normal walking, reduced energy expenditure, and improved quality of life. The research evidence makes it difficult not to question whether these benefits are valid and worth striving to achieve. When you consider that persons who undergo PFA are typically in the later years of their life and have limited mobility, it raises the question of whether we place too much emphasis on achieving the purported functional benefits of PFA and too little emphasis on achieving primary wound healing and mitigating the high rates of complications and subsequent amputation. If further research supports what we see emerging in the evidence, there will be a case to be made for selecting the level of PFA based primarily on the potential for wound healing, rather than trying to strike a balance with the perceived functional benefits. This may mean that transtibial amputation is preferable in many cases, given the lower rates of complications and secondary amputation, very similar function in terms of walking and energy expenditure, and similar lived experience of limb loss when compared with persons with PFA. Further research is needed to better understand the complications and benefits of PFA to make this a more viable, first-and-final amputation procedure.

Surgical Treatment of Diabetic Foot Disease / 임상당뇨병

Diabetic foot diseases which require surgical treatment consists of diabetic foot ulcer, infection and neuropathic arthropathy. Surgical procedures for diabetic foot ulcers and infections such as drainage, debridement, partial foot amputation and major limb amputation are most common procedures and arthodesis with or without deformity correction can be performed for specific diabetic neuropathic arthropathies. Underlying pathomechanism of diabetic foot disease includes diabetic peripheral neuropathy and vasculopathy. Treating physicians should be aware that concomitant complications of long-standing diabetic status such as cardiovascular and renal dysfunction should be addressed to treat intractable diabetic foot diseases successfully. However, with advent of adjuvant treatment which increases vascular supply on ischemic limb disease, proper surgical treatment on diabetic foot disease can prevent or delay major limb amputations, sustaining functional capability of diabetic patients.