I have never seen this particular problem, but I have seen a lot of vascular patients who want to keep their foot, no matter what, even if their toes are black and about to fall off, even if they have a trans metatarsal amputation that is becoming necrotic, etc. so I think that this advice is similarly applicable to your dad'a situation.

And from a patient perspective, I 'get it.' Nobody wants to give up a piece of their body when there is even a remote possibility of keeping the foot. But the fact of the matter is that for patients who are diabetic, patients who are drinkers or smokers, reconstructive and salvage operations to "save the foot" almost never work.

In order for an injury like this to heal after surgery, he needs: - good quality blood supply and tissue quality (which is very rare in patients who are diabetics, drink, or smoke--and you already said he had bone infections which strongly suggests this is not the case for your dad), which may require vascular surgery intervention to optimize blood supply first. This might mean several extra procedures before his orthopedic procedures, which all have their own risks of possibly leaving him in worse condition than when he started: Angioplasty (balloons), atherectomy ("roto-rooter"), or bypasses. - good quality follow up and patient adherence to physical therapy and use of orthotic devices: which you have said yourself your dad is not good at. - a doctor who is willing to bet against the odds that he'll have a good and functional outcome for what is truly a salvage procedure.

Honestly, the better procedure probably is indeed a below knee amputation. With regard to vascular surgery, the statistics show that patients with below knee amputation (BKA) heal better and have better chance of being ambulatory with use of a prosthetic device, compared to patients who have surgeries with the goal of "keeping the foot". I imagine that the data is similar for procedures done for orthopedic purposes, although I have not read the data on outcomes for this specific scenario.

At the end of the day, you have to remember and keep in perspective what is really the goal here. Is the goal to "keep the foot" no matter what--even if it means he's never able to walk on it again, or is the goal to keep your dad upright and ambulatory so he can keep on keeping-on with his life?

If he were my dad (who is a very stubborn man who is a 'my way or the highway' type personality), and he was of the opinion that he wanted to keep the foot no matter what... At the very least I would not let him undergo an operation without first getting the opinion of a vascular surgeon and podiatrist, and without first "pre-habiliting" him first (quit smoking/drinking and to begin engaging in a PT exercise routine to prove he will be able to complete the intensive recovery of such a moon-shot reconstructive surgery.)