Amputation is a major health burden on the families, society, and on medical services as well. Traumatic limb amputation is a catastrophic injury and an irreversible act which is sudden and emotionally devastating for the victims. In addition, it causes inability to support self and the family and driving many patients toward various psychiatric disorders. Extensive information regarding the effects of amputation has not been ascertained and therefore it was decided to do a systematic review
Amputation is the removal of a limb by trauma, medical illness, or surgery. As a surgical measure, it is used to control pain or a disease process in the affected limb, such as malignancy or gangrene. In some cases, it is carried out on individuals as a preventative surgery for such problems. A special case is that of congenital amputation, a congenital disorder, where fetal limbs have been cut off by constrictive bands. In some countries, amputation of the hands, feet or other body parts is or was used as a form of punishment for people who committed crimes.[rx][rx][rx] Amputation has also been used as a tactic in war and acts of terrorism; it may also occur as a war injury. In some cultures and religions, minor amputations or mutilations are considered a ritual accomplishment.[rx][rx][rx]
There are 4 fascial compartments in the lower leg, containing muscles to the leg and foot and important neurovascular structures. While a BKA divides all compartments, a thorough grasp of the relevant anatomy is vital to controlling blood loss intraoperatively and preventing known complications.
The anterior tibial compartment lies anteromedial to the spine of the tibia and anterior to the fibula. Within the fascia lie the tibialis anterior, extensor hallucis longus, extensor digitorum longus, and peroneus tertius. Also in the anterior compartment are the deep peroneal nerve and the anterior tibial artery and vein. The anterior tibial artery is the main blood supply to the anterior compartment of the leg with reinforcement by the perforating branch of the peroneal artery. The lateral compartment lies posterior to the anterior compartment and directly lateral to the fibula. This contains the peroneus longus and brevis and the superficial branch of the peroneal nerve for much of its course. It derives the arterial supply from the branches of the peroneal artery. The posterior leg holds both the superficial and deep compartments, the superficial containing the soleus, gastrocnemius, and plantaris muscles. The deep, muscular compartment contains tibialis posterior and the great and common toe flexors. The tibial neurovascular structures lie within the deep compartment. The posterior tibial artery is the main blood supply of this compartment. It is very important to understand the vascular anatomy of the leg as skin flaps for amputation are planned according to the blood supply.
Types of Amputation
Lower limb, or leg, amputations can be divided into two broad categories – minor amputations and major amputations, Minor amputations generally refers to the amputation of digits. Major amputations are commonly referred to as below-knee amputation, above-knee amputation and so forth. Types of amputations include:
- Partial foot amputation – amputation of the lower limb distal to the ankle joint.
- Ankle disarticulation – amputation of the lower limb at the ankle joint.
- Trans-tibial amputation – amputation of the lower limb between the knee joint and the ankle joint, commonly referred to as a below-knee amputation.
- Knee disarticulation – amputation of the lower limb at the knee joint.
- Trans-femoral amputation – amputation of the lower limb between the hip joint and the knee joint, commonly referred to an above-knee amputation.
- Hip disarticulation – amputation of the lower limb at the hip joint.
- Trans-pelvic disarticulation – amputation of the whole lower limb together with all or part of the pelvis. This is also known as a hemipelvectomy or hindquarter amputation.
Common partial foot amputations include Chopart, Lisfranc and ray amputations, Common forms of ankle disarticulations include Syme,[rx] Pyrogoff and Boyd. A less commonly occurring major amputation is the Van Ness rotation/rotationplasty (foot being turned around and reattached to allow the ankle joint to be used as a knee).
- Partial hand amputation
- Wrist disarticulation
- Trans-radial amputation, commonly referred to as below-elbow or forearm amputation
- Elbow disarticulation
- Trans-humeral amputation, commonly referred to as above-elbow amputation
- Shoulder disarticulation
- Forequarter amputation
A variant of the trans-radial amputation is the Krukenberg procedure in which the radius and ulna are used to create a stump capable of a pincer action.
Facial amputations include but are not limited to
- Amputation of the ears
- Amputation of the nose (rhinotomy)
- Amputation of the tongue (glossectomy).
- Amputation of the eyes (enucleation).
- Amputation of the teeth. Removal of teeth, mainly incisors, is or was practiced by some cultures for ritual purposes (for instance in the Iberomaurusian culture of Neolithic North Africa).
- amputation of the breasts (mastectomy).
- amputation of the testicles (castration).
- amputation of the penis (penectomy).
- amputation of the foreskin (circumcision).
- amputation of the clitoris (clitoridectomy).
Hemicorporectomy, or amputation at the waist, and decapitation, or amputation at the neck, are the most radical amputations. Genital modification and mutilation may involve amputating tissue, although not necessarily as a result of injury or disease.
In some rare cases when a person has become trapped in a deserted place, with no means of communication or hope of rescue, the victim has amputated his or her own limb. The most notable case of this is Aron Ralston, a hiker who amputated his own right forearm after it was pinned by a boulder in a hiking accident and he was unable to free himself for over five days.[rx]
Body integrity identity disorder is a psychological condition in which an individual feels compelled to remove one or more of their body parts, usually a limb. In some cases, that individual may take drastic measures to remove the offending appendages, either by causing irreparable damage to the limb so that medical intervention cannot save the limb, or by causing the limb to be severed.
Causes of Amputation
- Diabetic vasculopathy
- Sepsis with peripheral necrosis
- Cancerous bone or soft tissue tumors (e.g. osteosarcoma, chondrosarcoma, fibrosarcoma, epithelioid sarcoma, Ewing’s sarcoma, synovial sarcoma, sacrococcygeal teratoma, liposarcoma), melanoma
- Severe limb injuries in which the limb cannot be saved or efforts to save the limb fail.
- Traumatic amputation (an unexpected amputation that occurs at the scene of an accident, where the limb is partially or entirely severed as a direct result of the accident, for example, a finger that is severed from the blade of a table saw)
- Amputation in utero (Amniotic band)
- Deformities of digits and/or limbs (e.g., proximal femoral focal deficiency, Fibular hemimelia)
- Extra digits and/or limbs (e.g., polydactyly)
- Bone infection (osteomyelitis) and/or diabetic foot infections
Sometimes professional athletes may choose to have a non-essential digit amputated to relieve chronic pain and impaired performance.
- Australian Rules footballer Daniel Chick elected to have his left ring finger amputated as chronic pain and injury was limiting his performance.[rx]
- Rugby union player Jone Tawake also had a finger removed.[rx]
- National Football League safety Ronnie Lott had the tip of his little finger removed after it was damaged in the 1985 NFL season.
- Amputation is used as a legal punishment in a number of countries, among them Saudi Arabia, Yemen, United Arab Emirates, and Iran
Traumatic amputation is uncommon in humans (1 per 20,804 population per year). Loss of limb usually happens immediately during the accident, but sometimes a few days later after medical complications. Statistically the most common causes of traumatic amputations are:[rx]
- Traffic accidents (cars, motorcycles, bicycles, trains, etc.)
- Labor accidents (equipment, instruments, cylinders, chainsaws, press machines, meat machines, wood machines, etc.)
- Diseases, such as blood vessel disease (called peripheral vascular disease or PVD), diabetes, blood clots, or osteomyelitis (an infection in the bones).
- Injuries, especially of the arms. Seventy-five percent of upper extremity amputations are related to trauma.
- Surgery to remove tumors from bones and muscles.
- Agricultural accidents, with machines and mower equipment
- Electric shock hazards
- Firearms, bladed weapons, explosives
- Violent rupture of ship rope or industry wire rope
- Ring traction (ring amputation, de-gloving injuries)
- Building doors and car doors
- Gas cylinder explosions[rx]
- Other rare accidents[rx]
- Severe injury (from a vehicle accident or serious burn, for example)
- Cancerous tumor in the bone or muscle of the limb
- Serious infection that does not get better with antibiotics or other treatment
- Thickening of nerve tissue, called a neuroma
- Arterial insufficiency leading to death or decay of body tissue (gangrene)
- Chronic leg ulcer leading to Septicaemia
- Infection e.g. Bone infection (Osteomyelitis)
- Malignant tumours e.g. sarcoma (cancer of the connective tissue)
- Trauma (limb buried under / crushed by heavy object, limb damaged by car accident, stabbing, gunshot, animal bite etc.); in some cases leading to
- Traumatic amputation: a physical (non-surgical) separation of the limb in the course of the traumatic event
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|Squamous cell carcinoma||7||5.3|
|Malignant fibrous histiocytoma||1||0.8|
|Diabetic foot gangrene||6||4.5|
|Severe surgical site infection||2||1.5|
|Wound infection||Severe crush injury||10|
|Diabetic foot gangrene||1|
|Wound dehiscence||Severe crush injury||2|
|Diabetic foot gangrene||1|
|Surgical site infection||1|
|Stump osteomyelitis||Severe crush injury||2|
Single digit injury through flexor tendon zone II
Prolonged warm ischaemic time
Improperly preserved amputated part
Other life-threatening injuries
Previous surgery to affected finger
‘Red line’ or ‘red ribbon’ sign (seen in vessels during surgery), which predicts the level of intimal damage in the vessel
Once the patient arrives in the operating theater, the amputated part should undergo a careful assessment for suitability for replanting. All structures should be dissected and identified, especially the neurovascular bundle. If no suitable vessels are identified, then replantation should not proceed. Usually, there is an order for repair of structures:
Bone fixation with or without bone shortening to allow repair of soft tissue
Tendon repair – extensor and flexor tendons
Venous anastomosis (if suitable veins are present)
Bone fixation should be simple and quick to perform, but it also depends on the configuration of bony injuries. Usually, two Kirschner wires are an option, but other fixation methods may also be used (i.e., plate fixation). Occasionally, bone shortening is required before fixation to allow for soft tissue closure and repair of neurovascular structures without excessive tension.
Diagnosis of Amputation
Hand dominance, occupation, time of injury, mechanism of injury, other associated injuries, comorbidities and NPO status.
Level of amputation, structures involved, neurovascular status, function, and degree of contamination (if relevant). It is vital to assess the amputated part and ultimately determine its suitability for replanting respective to the mechanism of injury (e.g., crush, guillotine-style, avulsion).
The assessment is likely to include:
- a thorough medical examination – assessing your physical condition, nutritional status, bowel and bladder function, your cardiovascular system (heart, blood and blood vessels) and your respiratory system (lungs and airways)
- an assessment of the condition and function of your healthy limb – removing one limb can place extra strain on the remaining limb, so it’s important to look after the healthy limb
- a psychological assessment – to determine how well you’ll cope with the psychological and emotional impact of amputation, and whether you’ll need additional support
- an assessment of your home, work and social environments – to determine whether any additional provisions will need to be made to help you cope
You’ll also be introduced to a physiotherapist, who will be involved in your post-operative care. A prosthetist (a specialist in prosthetic limbs) will advise you about the type and function of prosthetic limbs or other devices available.
Finger amputations classification is generally according to the level of amputation. The Sebastian and Chung classification is outlined below[rx]:
Zone 1 distal amputations
Zone 1A – distal to lunula, through the sterile matrix
Zone 1B – between lunula and nailbed
Zone 1 proximal amputations
Zone 1C – between flexor digitorum profundus insertion and neck of the middle phalanx
Zone 1D – between the neck of the middle phalanx and insertion of the flexor digitorum superficialis
Laboratory:(optional depending on clinical scenario)
- CBC (complete blood count) to assess for blood loss
- Coagulation studies (only if the patient is known to be on anticoagulants)
- Plain radiograph of the affected finger/hand and amputated part; this allows assessment of bony injuries, bone quality and guide decisions regarding bony fixation methods. Angiograms are normally not requested unless it forms part of investigations for other injuries.
How Do I Get Ready For an Amputation
Ask your surgeon to tell you what you should do before your amputation. Below is a list of common steps that you may be asked to do:
- Your surgeon will explain the procedure and ask if you have any questions.
- You will be asked to sign a consent form that gives permission to do the procedure. Read the form carefully and ask
- questions if something is not clear.
- Along with a complete medical history, your surgeon may do a physical exam to ensure you are in otherwise good health. You may have blood or other tests.
- You will be asked to fast for 8 hours, generally after midnight.
- If you are pregnant or think you may be, tell your surgeon.
- Tell your surgeon if you are sensitive to or are allergic to any medicines, latex, tape, or local and general anesthesia.
- Tell your surgeon of all medicines (prescription and OTC) and herbal supplements that you are taking.
- Tell your surgeon if you have a history of bleeding disorders or if you are taking any blood-thinning (anticoagulant) medicines, aspirin, or other medicines that affect blood clotting. You may be told to stop these medicines before the procedure.
- You may be measured for an artificial limb.
- You may receive a sedative to help you relax.
- Based on your medical condition, your surgeon may request other specific preparation.
What Happens During an Amputation
Talk with your surgeon about what to expect during your procedure. An amputation requires a stay in a hospital. Procedures may vary depending on the type of amputation, your condition, and your surgeon’s practices. An amputation may be done while you are asleep under general anesthesia, or while you are awake under spinal anesthesia. If spinal anesthesia is used, you will have no feeling from your waist down. Your surgeon will discuss this with you in advance.
Generally, an amputation follows this process
- You will be asked to remove any jewelry or other objects that may interfere with the procedure.
- You will be asked to remove your clothing and put on a gown.
- An IV line may be started in your arm or hand.
- You will be positioned on the operating table.
- The anesthesiologist will monitor your heart rate, blood pressure, breathing, and blood oxygen level during the procedure.
- A thin, narrow tube (catheter) may be inserted into your bladder to drain urine.
- he skin over the surgical site will be cleansed with an antiseptic solution.
- To determine how much tissue to remove, the surgeon will check for a pulse at a joint close to the site. Skin temperatures, color, and the presence of pain in the diseased limb will be compared with those in a healthy limb.
- After the incision, your surgeon may decide that more of the limb needs to be removed. The surgeon will keep as much of the functional stump length as possible. He or she will also leave as much healthy skin as possible to cover the stump area.
- If the amputation is due to injury, the crushed bone will be removed and smoothed out to help with the use of an artificial limb. If needed, temporary drains that will drain blood and other fluids may be inserted.
- After completely removing the dead tissue, the surgeon may decide to close the flaps. This is called a closed amputation. Or the surgeon may decide to leave the site open. This is called open flap amputation. In a closed amputation, the wound will be sutured shut right away. This is usually done if there is little risk of infection. In an open flap amputation, the skin will remain drawn back from the amputation site for several days so any infected tissue can be cleaned off. At a later time, once the stump tissue is clean and free of infection, the skin flaps will be sutured together to close the wound.
- A sterile bandage or dressing will be applied. The type of dressing used will depend on the type of surgery done.
- The surgeon may place a stocking over the amputation site to hold drainage tubes and wound dressings, or the limb may be placed in traction or a splint.
What Happens After an Amputation
In the hospital
- After the procedure, you will be taken to the recovery room. Your recovery will vary depending on the type of procedure done and anesthesia used. The blood flow and feeling of the affected extremity will be checked. Once your blood pressure, pulse, and breathing are stable and you are alert, you will be taken to your hospital room.
- You will get pain medicines and antibiotics as needed. The dressing will be changed and watched closely.
- You will start physical therapy soon after your surgery. Rehabilitation is designed for your specific needs. It may include gentle stretching, special exercises, and help getting in and out of bed or a wheelchair. If you had a leg amputation, you will learn how to bear weight on your remaining limb.
- There are specialists who make and fit prosthetic devices. They will visit you soon after surgery and will instruct you how to use the prosthesis. You may begin to practice with your artificial limb as early as 10 to 14 days after your surgery, depending on your comfort and wound healing process.
- After amputation, you will stay in the hospital for several days. You will get instructions as to how to change your dressing. You will be discharged home when the healing process is going well and you are able to take care of yourself with assistance.
- After surgery, you may have emotional concerns. You may have grief over the lost limb or a physical condition known as phantom pain. This is pain or other feeling in your amputated limb. If this is the case, you may receive medicines or other types of nonsurgical treatments.
The development of the science of microsurgery over last 40 years has provided several treatment options for a traumatic amputation, depending on the patient’s specific trauma and clinical situation:
- 1st choice – Surgical amputation – break – prosthesis
- 2nd choice – Surgical amputation – transplantation of other tissue – plastic reconstruction.
- 3rd choice – Replantation – reconnection – revascularisation of amputated limb, by microscope (after 1969)
- 4th choice –Transplantation of cadaveric hand (after 2000),[rrx][rx]
Medications that may be used to help relieve pain include:
- Non-steroidal anti-inflammatory drugs (NSAIDs) – such as ibuprofen
- Anticonvulsants – such as carbamazepine or gabapentin
- Antidepressants – such as amitriptyline or nortriptyline (these medications work directly on the nerves in your leg)
- Opioids – such as codeine or morphine
- Corticosteroid – or local anaesthetic injections
Self-help measures and complementary therapy
There are several non-invasive techniques that may help relieve pain in some people. They include:
- Checking – the fit of your prosthesis and making adjustments to make it feel more comfortable
- Applying heat or cold to your limb – such as using heat or ice packs, rubs and creams
- Massage – to increase circulation and stimulate muscles
- Acupuncture – thought to stimulate the nervous system and relieve pain
- Transcutaneous electrical nerve stimulation (TENS) – where a small, battery-operated device is used to deliver electrical impulses to the affected area of your body, to block or reduce pain signals
Research has shown that people who spend 40 minutes a day imagining using their phantom limb, such as stretching out their “fingers” or bunching up their “toes”, experience a reduction in pain symptoms. This may be related to the central theory of phantom limb pain (that the brain is looking to receive feedback from the amputated limb), and these mental exercises may provide an effective substitution for this missing feedback.
Another technique, known as mirror visual feedback, involves using a mirror to create a reflection of the other limb. Some people find that exercising and moving their other limb can help relieve the pain from a phantom limb.
In addition to your primary care doctor and surgeon, other medical professionals involved in your treatment plan may include:
- An endocrinologist – who is a physician with special training in the treatment of diabetes and other hormone-related disorders
- A physical therapist – who will help you regain strength, balance and coordination and teach you how to use an artificial (prosthetic) limb, wheelchair or other devices to improve your mobility
- An occupational therapist – who specializes in therapy to improve everyday skills, including teaching you how to use adaptive products to help with everyday activities
- A mental health provider – such as a psychologist or psychiatrist, who can help you address your feelings or expectations related to the amputation or to cope with the reactions of other people
- A social worker – who can assist with accessing services and planning for changes in care
Complications classify according to the time of onset[rx]
Arterial insufficiency– Arterial thrombosis presents typically as a pale, cool and pulseless digit- It is vital during the post-operative period to maximize blood flow through the anastomoses and prevent thrombosis
- Venous congestion typically presents as a purple digit with brisk capillary refill and swelling
Concerns of possible anastomosis failure or thrombosis should prompt urgent return to theatre for salvage – in cases of venous congestion, leech therapy or anticoagulation may be considered to improve venous return
High blood sugar levels
Nerve damage in the feet (peripheral neuropathy)
Calluses or corns
Poor blood circulation to the extremities (peripheral artery disease)
A history of foot ulcers
A past amputation
High blood pressure, above 140/80 millimeters of mercury (mmHg)
Postoperative and Rehabilitation Care
Maintain adequate hydration and circulation volume
Keep the affected limb elevated and warm
Frequent monitoring of the replant capillary refill, color, and temperature
Avoid dressings changes in the first 48 to 72 hours to minimize manipulation of the repair
In cases of artery-only replants, consider stab incision to the distal amputated tip and apply heparin soaked gauze to allow venous drainage or use leeches instead. This treatment can end once the finger becomes pink with normal capillary refill thus indicating adequate venous drainage
Some patients require further surgery to improve their function, such as tenolysis, bone grafting, tendon transfer, etc.[rx] On average, following upper limb amputations, patients return to work within 2 to 3 months after injury.[rx] Studies show that functional recovery is better in more distal injuries than proximal, both in terms of movement and power.[rx]
Deterrence and Patient Education
Good health and safety regulations – to provide a safe working environment and reduce occupation-related injuries
Public information leaflet/public awareness campaign – same objective as above, but to ensure a safe home environment for work and recreation, e.g., BBC News article in May 2018, warning the public of DIY and gardening accidents
Pearls and Other Issues
Once a patient with an amputation injury arrives in hospital, a speedy but thorough assessment is essential to minimize the delay to definitive surgical management
Often, amputated parts are brought to the emergency department (although sometimes forgotten at the scene or referring hospital) in inappropriate storage. As a specialist center, it is crucial to inform referring units of the best way to preserve the amputated part, to label it with the patient’s details and keep it with the patient to avoid loss
Early involvement of specialists where possible
Take account of patient factors, i.e., age, occupation, comorbidities, and also patient wishes – replantation requires long and complex surgery, hospital admission, the risk of complications, long rehabilitation, and risk of an incomplete return to normal function.
This may not be acceptable in some patients, especially in those who are self-employed and cannot take prolonged time off work
As such, terminalization of the affected finger may allow early return to work and normal function for the patient – if possible, the patient needs to understand their options and the potential outcome of each
Good rehabilitation process – early involvement of hand therapists
Rehabilitation after amputation
Loss of a limb produces a permanent disability that can impact a patient’s self-image, self-care, and mobility (movement). Rehabilitation of the patient with an amputation begins after surgery during the acute treatment phase. As the patient’s condition improves, a more extensive rehabilitation program is often begun.
The success of rehabilitation depends on many variables, including the following:
- Level and type of amputation
- Type and degree of any resulting impairments and disabilities
- Overall health of the patient
It is important to focus on maximizing the patient’s capabilities at home and in the community. Positive reinforcement helps recovery by improving self-esteem and promoting independence. The rehabilitation program is designed to meet the needs of the individual patient. Active involvement of the patient and family is vital to the success of the program.
The goal of rehabilitation after an amputation is to help the patient return to the highest level of function and independence possible, while improving the overall quality of life — physically, emotionally, and socially.
In order to help reach these goals, amputation rehabilitation programs may include the following:
- Treatments to help improve wound healing and stump care
- Activities to help improve motor skills, restore activities of daily living (ADLs), and help the patient reach maximum independence
- Exercises that promote muscle strength, endurance, and control
- Fitting and use of artificial limbs (prostheses)
- Pain management for both postoperative and phantom pain (a sensation of pain that occurs below the level of the amputation)
- Emotional support to help during the grieving period and with readjustment to a new body image
- Use of assistive devices
- Nutritional counseling to promote healing and health
- Vocational counseling
- Adapting the home environment for ease of function, safety, accessibility, and mobility
- Patient and family education
The amputation rehabilitation team
Rehabilitation programs for patients with amputations can be conducted on an inpatient or outpatient basis. Many skilled professionals are part of the amputation rehabilitation team, including any or all of the following:
- Orthopedists/orthopedic surgeons
- Other specialty doctors
- Rehabilitation specialists
- Physical therapist
- Occupational therapist
- Social worker
- Recreational therapist
- Case manager
- Vocational counselor
Types of Rehabilitation Programs for Amputations
There are a variety of treatment programs, including the following:
- Acute rehabilitation programs
- Outpatient rehabilitation programs
- Day-treatment programs
- Vocational rehabilitation programs
Preventing foot ulcers
The best strategy for preventing complications of diabetes — including foot ulcers — is proper diabetes management with a healthy diet, regular exercise, blood sugar monitoring and adherence to a prescribed medication regimen.
Proper foot care will help prevent problems with your feet and ensure prompt medical care when problems occur. Tips for proper foot care include the following:
- Inspect your feet daily – Check your feet once a day for blisters, cuts, cracks, sores, redness, tenderness or swelling. If you have trouble reaching your feet, use a hand mirror to see the bottoms of your feet. Place the mirror on the floor if it’s too difficult to hold, or ask someone to help you.
- Wash your feet daily – Wash your feet in lukewarm (not hot) water once a day. Dry them gently, especially between the toes. Use a pumice stone to gently rub the skin where calluses easily form. Sprinkle talcum powder or cornstarch between your toes to keep the skin dry. Use a moisturizing cream or lotion on the tops and bottoms of your feet to keep the skin soft. Preventing cracks in dry skin helps keep bacteria from getting in.
- Don’t remove calluses or other foot lesions yourself – To avoid injury to your skin, don’t use a nail file, nail clipper or scissors on calluses, corns, bunions or warts. Don’t use chemical wart removers. See your doctor or foot specialist (podiatrist) for removal of any of these lesions.
- Trim your toenails carefully – Trim your nails straight across. Carefully file sharp ends with an emery board. Ask for assistance from a caregiver if you are unable to trim your nails yourself.
- Don’t go barefoot – To prevent injury to your feet, don’t go barefoot, even around the house.
- Wear clean, dry socks – Wear socks made of fibers that pull sweat away from your skin, such as cotton and special acrylic fibers — not nylon. Avoid socks with tight elastic bands that reduce circulation or socks with seams that could irritate your skin.
- Buy shoes that fit properly – Buy comfortable shoes that provide support and cushioning for the heel, arch and ball of the foot. Avoid tightfitting shoes and high heels or narrow shoes that crowd your toes.If one foot is bigger than the other, buy shoes in the larger size. Your doctor may recommend specially designed shoes (orthopedic shoes) that fit the exact shape of your feet, cushion your feet and evenly distribute weight on your feet.
- Don’t smok – Smoking impairs circulation and reduces the amount of oxygen in your blood. These circulatory problems can result in more-severe wounds and poor healing. Talk to your doctor if you need help to quit smoking.
- Schedule regular foot checkups Your doctor or podiatrist can inspect your feet for early signs of nerve damage, poor circulation or other foot problems. Schedule foot exams at least once a year or more often if recommended by your doctor.
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