Biomechanical Considerations of the Neuropathic Foot: A Primer for Plastic Surgeons

Chronic lower extremity (LE) wounds, especially in diabetic patients with peripheral neuropathy, are a leading cause of nontraumatic amputation. These wounds often result from underlying biomechanical deformity and altered gait mechanics in the insensate foot. This primer outlines key biomechanical principles for plastic surgeons involved in limb salvage, emphasizing the importance of early recognition, deformity classification and considerations, and comprehensive vascular assessment prior to intervention. A multidisciplinary, biomechanically informed approach, integrating vascular, podiatric, and plastic surgical expertise, is critical for effective wound management. Surgical strategies may be guided by wound location and associated deformity. For example, tibiotalocalcaneal (TTC) fusion addresses plantar hindfoot wounds linked to ankle dorsiflexion instability, while Achilles tendon lengthening (TAL) treats forefoot wounds caused by plantarflexion contracture. Varus or valgus deformities of the lateral or medial foot may require tendon transfers or joint fusion, and Charcot neuroarthropathy often necessitates osteotomy and/or arthrodesis. Hallux and lesser toe wounds, commonly due to digital contractures, are treated with tendon transfers, arthroplasty, or fusion. In some cases, transmetatarsal amputation offers both structural and functional balance and preserves ambulatory function. Ultimately, successful limb preservation hinges on early biomechanical correction, vascular optimization, infection control, and durable soft tissue reconstruction. This integrated approach enhances healing, reduces recurrence, and improves long-term mobility and quality of life in this high-risk population.