The thought of amputation is a terrible one and one that hopefully few of us will have to face. An amputation usually refers to the removal of the whole or part of an arm/hand or a leg/foot. Amputations can happen after an injury or be surgically performed. In amputations due to vascular problems legs are most commonly amputated. Vascular surgeons frequently have to perform amputations of toes or legs. It is one of the oldest surgical procedures with reports of artificial limbs going back to as long as 2000 years ago.

The vast majority of amputations are performed because the arteries of the legs have become blocked due to hardening of the arteries (atherosclerosis). Blockages in the arteries result in insufficient blood supply to the limb. Because diabetes can cause hardening of the arteries, about 30-40% of amputations are performed in patients with diabetes.

I agree that it is a horrible thought but it is a sad fact for many as particularly patients with diabetes can develop foot/toe ulceration and about 7% of patients will have an active ulcer or a healed ulcer. Ulcers are recurrent in many patients and approximately 5-15% of diabetic patients with ulcers will ultimately require an amputation. Because hardening of the arteries occurs most commonly in older men who smoke, the majority of amputations for vascular disease occur in this group. Diabetes may be an important factor in nearly 40% of patients undergoing major amputation. When hardening of the arteries becomes so severe that gangrene develops or pain becomes constant and severe, amputation may be the only option. If amputation is not performed in these circumstances infection can develop and threaten the life of the patient. Sometimes bypass surgery can be performed to avoid amputation, but not all patients are suitable for bypass surgery. Before amputation, the limb can cause serious problems with infection and pain and may even be a threat to the life of some patients.
Less commonly serious accidents can lead to the loss of a limb, as can the development of a tumour or cancer in a limb. These amputations tend to occur in younger patients.

Yes broadly speaking amputations can be divided into minor and major. Most vascular surgeons will have extensive experience in this type of surgery.
Minor amputations are amputations where only a toe or part of the foot is removed. A ray amputation is a particular form of minor amputation where a toe and part of the corresponding metatarsal bone is removed as shown in the diagram below left. A forefoot amputation can sometimes be helpful in patients with more than one toe involved by gangrene. In this operation all of the toes and the ball of the foot is removed.
Major amputations are amputations where part of the leg is removed. These are usually below the knee or above the knee.
Occasionally an amputation of just the foot can be performed with a cut through the ankle joint. This is not suitable for the majority of patients, but can rarely be an option in some patients with diabetes.

Yes that is sad but true but it is particularly important for this amputation that the posterior tibial artery is patent and has a reasonable blood flow. This artery is found on the inside of the foot just below the ankle. A surgeon may advise if this operation may be possible.

Amputations through the knee joint or just above the knee joint can also sometimes be performed. They were much more popular amputations in the past but there is little or no advantage for present day patients compared with above knee amputation. If a major amputation is to be performed then a below knee amputation will always give the patient the best chance of remaining mobile and walking post-operatively.

Sadly a very good friend of mine had to have a minor amputation. It is a huge thing for someone, but he has recovered well. After minor amputations the wound is not always closed completely with stitches. If infection is present or too much skin has had to be removed then the surgeon may leave the amputation wound open. When a ray amputation is performed the wound is usually left open to heal. This sounds awful and to the untrained eye the resulting wound can appear dreadful. If the wound is open do not be disheartened. If the conditions are right for healing these wounds can heal well over a period of 1-3 months and leave a fully functioning leg and foot. It is possible to walk virtually normally after losing toes. Even after a forefoot amputation where all the toes are removed, walking is usually straightforward.

This sort of operation is performed frequently for foot infections in patients with diabetes, which my friend had.