Chapter 31: Amputations

General Surgical Technique

Digital Amputations
MPJ Amputations
Transmetatarsal Amputations
Tarsometatarsal Amputations (Lisfranc's)
Midfoot Amputations (Chopart's)
Amputation of the Ankle (Syme's, Boyd, Pirogoff)
Below Knee Amputation
 AMPUTATIONS
Amputation that includes disarticulation is an ancient surgical procedure,
with techniques that have evolved over the centuries. In the last 20 years
research and advances in surgical technique have led to a more scientific
approach, so that the indications are more exact, and the level of amputation
is more distal. The combined approach of vascular surgeon, podiatrist, and
plastic surgeon have helped prevent major amputations, or allowed
amputations to be performed more distally on the extremity, resulting in less
morbidity and lower mortality.
General Surgical Technique
1. Before surgery the general condition of the patient must be stabilized
(control of infection, blood sugar, hydration, etc.)

2. Surgical handling of skin must be meticulous

3. A tourniquet is used except in the presence of vascular disease, and the

limb is exanguinated if no infection or tumor is present

4. Flaps should be planned to provide sensate skin over the stump 5. The
scar must not adhere to the underlying bone

6. Blood vessels should be carefully ligated and nerves divided as proximally

as possible under gentle traction to allow them to retract (these divided
nerves should not lie close to the bone)

7. The bone end should be rounded and beveled appropriately

8. Drainage of the stump is mandatory

9. If infection is present, and the viability of the tissues is in question, the

wound should be left open

Digital Amputations
1. Indications:
a. In gangrene of the toes (need adequate proximal arterial flow)
b. Malignant or large, deforming, benign tumors of the digits

2. Effects of digital amputation:

a. Amputation of all the toes allows the patient to have a normal gait while
walking slowly
b. Amputation of the 2nd toe alone results in the hallux going into a valgus
position
c. Amputation of the hallux only does not alter gait when the patient is
walking slowly but causes a limp with a quick walk because of loss of push-off
3. Procedure:
a. Short dorsal flap at the level of the bone resection and a long plantar flap
can then be reflected over the stump
b. The tendons and nerves should be sectioned after gentle traction to allow
them to retract
c. Round the bone end to prevent a distal keratoma

MPJ Amputations
1. Indications:
a. Severe trauma
b. Gangrene

2. Procedure:
a. A long posterior flap should be used and the dorsal incision made
approximately 1 cm distal to the MPJ
b. Specifically in the 1st ray, the flexor and extensor tendons and intrinsic
muscles should be sutured over the metatarsal head to prevent retraction of
the sesamoids to stabilize the 1 st ray (groove the met head to hold the
tendons)
c. If the sesamoids are not present the prominence on the underside of the
1st metatarsal head should be removed
d. After the articular cartilage of the 1st metatarsal is removed, the
metatarsal is beveled medially to provide better shape to the final
amputation stump
e. Also the lateral third of the 5th metatarsal head should be removed with
this disarticulation
f. If there is a sub-metatarsal callus or ulceration present, a plantar
condylectomy should be performed

Transmetatarsal Amputations
1. Indications:
a. Ischemia
b. Gangrene
c. Osteomyelitis
d. Frostbite
e. Trauma

2. Procedure:
a. Can be single ray resection for the treatment of infection, and is most
successful in the 1 st and 5th ray
b. A racket incision with a dorsal limb
c. The metatarsals should be sectioned at the level of the dorsal skin incision,
in a line curving proximally from the medial side
d. Careful attention should be given to the digital nerves, and must be seen
to retract or a painful "stump" neuroma can develop
e. The plantar surface of the metatarsals should be beveled to allow better
weight distribution
 1. Complications: This procedure has fallen into disfavor because muscle
imbalance resulted in severe equinus deformity. A tendo Achilles lengthening
and reattachment of the extensor tendons is recommended to prevent this

2. Procedure: Reattachment of the extensors should be considered. The

base of the second metatarsal should be left in place in line with the medial
and lateral cuboid joints
1. Complications: This amputation has a greater tendency to result in an
equinus deformity because of loss of the insertion of the tibialis anterior
tendon and toe dorsiflexors

2. Procedure: The tibialis anterior tendon must be dissected free as distally

as possible and anchored through or around the neck of the talus. A tendo
Achilles lengthening is a useful adjunct. The intrinsic muscle bellies can be
used to cover the distal stump

Amputation at the Ankle (Syme's, Boyd, Pirogoff)

1. Syme's amputation:
a. Indications: A Syme's through-ankle amputation is indicated in some
congenital deformities, tumors, and management of the diabetic foot.
Protective sensation to the heel pad must be present because this is the end
stump. The heel pad must be stable and adhere to the the end of the tibia to
prevent migration
b. Procedure: The skin is 1st marked 1 cm below the lateral malleolus and 2
cm below the medial malleolus. These marks are joined by a horizontal skin
incision. A vertical skin incision is then made to joint these points. The
incisions are deepened cutting structures to expose the calcaneus and the
neck of the talus. After the anterior capsule of the ankle joint is sectioned,
the foot is forcibly plantarflexed and the talus pulled forward and downward.
The collaterals are sectioned. The Achilles once exposed is divided near its
insertion near the calcaneus. The calcaneus is dissected free from the soft
tissues. A transverse saw cut is made through the lower end of the tibia and
lateral malleolus. The anterior tibial, posterior tibial and greater saphenous
are ligated. The calcaneal nerve branch of the posterior tibial nerve must be
preserved

2. Boyd amputation: Part of the calcaneus is retained and fused to the

lower end of the tibia

3. Pirogoff amputation: A technique based on rotation of the calcaneus

90° and a fusion of the calcaneus to the lower end of the tibia

Below Knee Amputation

1. Indications:
a. Vascular disease
b. Trauma
c. Tumor
d. Diabetes complications
e. Infection
2. Procedure: Suitable flaps should be planned. The stump should measure
between 12.5 cm-17.5 cm depending upon body height. The anterior surface
of the tibia should be beveled, and the fibula should be cut 3 cm proximal to
this