In limb preservation, the hardest question is often not, “Can we save this foot?” It is, “What will this patient be able to do with the foot we save?”
A new paper from our Georgetown colleagues tackles that question in an unusually demanding setting. The patient has already lost the front of the foot through a transmetatarsal, Lisfranc, or Chopart amputation. Later, heel osteomyelitis threatens the same limb from the opposite direction. The next salvage operation is therefore literally bidirectional: a midfoot amputation anteriorly and a partial calcanectomy posteriorly.
The full authorship team deserves recognition: Craig J. Verdin, Nicole K. Cates, Holly D. Shan, Karen K. Evans, Christopher E. Attinger, John S. Steinberg, and Jayson N. Atves. Their report, “Bidirectional Limb Salvage and Its Impact on Residual Limb Survivorship: Is a Partial Calcanectomy in Ambulatory Midfoot Amputees Worthwhile?”, was published in the Journal of the American Podiatric Medical Association.
What they observed
The team retrospectively studied nine ambulatory patients – 10 feet – treated at Georgetown University Hospital. Eight patients had diabetes, seven had peripheral arterial disease, and five had chronic kidney disease. Before the heel operation, five feet had a transmetatarsal amputation, three a Lisfranc amputation, and two a Chopart amputation. Partial calcanectomy followed, on average, about 25 months later.
At a mean follow-up of 19.5 months:
- 8 of 10 limbs avoided below-knee amputation, an 80% limb-salvage rate.
- Two feet developed dehiscence requiring intervention.
- Two limbs ultimately required below-knee amputation because of recurrent heel infection.
- Six of nine patients were ambulatory at the latest follow-up, including two who walked with a prosthesis after below-knee amputation.
- Among the seven patients whose bidirectionally treated limb was retained, four remained ambulatory – 57.1%.
That final distinction is the center of the story. Limb salvage and functional salvage overlap, but they are not synonyms.
The biomechanics run in both directions
A midfoot amputation shortens the lever arm and redistributes plantar load. A partial calcanectomy removes infected heel bone but also changes the posterior weight-bearing construct. Combine the two, and the remaining foot must manage load between two surgically altered ends.
Yet the series suggests that this demanding construct can remain viable. All five transmetatarsal-level limbs were salvaged in this small cohort, compared with two of three Lisfranc-level limbs and one of two Chopart-level limbs. That gradient is clinically plausible as the pedal lever arm becomes progressively shorter, but with only 10 feet it should be treated as a signal, not a rule.
Perfusion also looms large. Both major-amputation failures occurred in patients described as having no named-vessel runoff suitable for revascularization, despite collateral flow judged sufficient for an attempted salvage. This does not prove causation, but it reinforces a practical point: heel salvage is never only about bone. Blood flow, the soft-tissue envelope, infection control, tendon balance, offloading, and the patient’s functional goals all travel together.
From the Hurricane incision to vertical contouring
This work also extends a line of thinking that has been developing for years.
In 2010, Tim Fisher and I described the “Hurricane” incisional approach for partial calcanectomy: a serpentine route designed to provide exposure while facilitating closure along relaxed skin-tension lines. We later highlighted that manuscript here on Diabetic Foot Online.
The Georgetown group subsequently advanced the vertical contour calcanectomy, reshaping the calcaneus to address infected bone and help achieve soft-tissue closure without excessive tension. Nicole Cates and colleagues then reported functional outcomes in a clinical case series.
The present paper asks the next question: can these posterior salvage ideas still work after the anterior foot has already been shortened? Its answer is a qualified yes – in a carefully selected patient, with realistic expectations.
What this study cannot tell us
This is a small, retrospective, single-center case series without a matched below-knee amputation comparison group. The amputation levels and calcanectomy techniques were heterogeneous, and “ambulatory” is a broad endpoint that cannot capture gait quality, energy expenditure, walking distance, assistive-device use, or patient-reported quality of life. The study therefore cannot establish that bidirectional salvage is superior to below-knee amputation, or identify a reliable threshold at which salvage becomes futile.
What it can do is make the decision more honest. An 80% rate of limb preservation is meaningful. So is the finding that only four of seven patients with retained bidirectionally salvaged limbs remained ambulatory. Both numbers belong in the same conversation.
The worthwhile operation is not simply the one that preserves the most anatomy. It is the one that gives a particular patient the best chance of a durable, usable, acceptable life.
Bottom line: Saving a foot is not automatically the same as saving gait – but neither is a below-knee amputation. Limb length, durable heel closure, perfusion, and meaningful ambulation must be designed together.
Earlier on Diabetic Foot Online
- Partial Calcanectomy in High-Risk Patients With Diabetes: Use and Utility of a “Hurricane” Incisional Approach
- SALSAism Entry: A Well Heeled Patient
- Diabetic Foot Video Series – including partial calcanectomy
References
- Verdin CJ, Cates NK, Shan HD, Evans KK, Attinger CE, Steinberg JS, Atves JN. Bidirectional Limb Salvage and Its Impact on Residual Limb Survivorship: Is a Partial Calcanectomy in Ambulatory Midfoot Amputees Worthwhile? J Am Podiatr Med Assoc. 2026;116(4):56.
- Fisher TK, Armstrong DG. Partial Calcanectomy in High-Risk Patients With Diabetes: Use and Utility of a “Hurricane” Incisional Approach. Eplasty. 2010;10:e17.
- Elmarsafi T, et al. The Vertical Contour Calcanectomy: An Alternative Surgical Technique to the Conventional Partial Calcanectomy. J Foot Ankle Surg. 2019;58(2):381-386.
- Cates NK, et al. The Vertical Contour Calcanectomy, an Alternative Approach to Surgical Heel Ulcers: A Case Series. J Foot Ankle Surg. 2019;58(6):1067-1071.
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