Steps for Great Toe Amputation
Great toe amputation should be performed using a systematic surgical approach that preserves maximum functional length while removing non-viable tissue, with the procedure tailored to the specific level of amputation required. 1
Preoperative Assessment
- Evaluate the need for amputation based on:
- Assess patient's hemodynamic status and overall physiologic reserve
- Determine the most distal level of amputation that will facilitate healing and provide maximal functional ability 2
- Consider preoperative antibiotic prophylaxis for open wounds or infection 2
Surgical Steps for Great Toe Amputation
1. Preparation
- Position patient supine with foot properly exposed and prepped
- Apply tourniquet if appropriate (contraindicated in severe peripheral arterial disease)
- Mark planned incision lines based on viable tissue
2. Incision and Exposure
- Create a plantar flap that is longer than the dorsal flap to ensure adequate padding for weight-bearing 2
- For distal amputations: make a "fish-mouth" or racquet-shaped incision around the toe
- For proximal amputations: consider a more elliptical incision that will facilitate closure
3. Dissection
- Identify and ligate digital vessels to prevent bleeding
- Identify and transect digital nerves proximal to the incision to prevent neuroma formation
- Expose the bone at the planned level of amputation
4. Bone Resection
- For distal phalangeal amputations: remove the distal portion of the phalanx
- For interphalangeal joint amputations: disarticulate at the joint 3
- For metatarsophalangeal joint amputations: consider preserving the base of the proximal phalanx when possible 4
- Smooth any sharp bone edges with a rongeur or bone file
5. Wound Management
- Irrigate the wound thoroughly to remove debris and reduce bacterial load
- Ensure adequate hemostasis
- Consider obtaining deep tissue cultures if infection is present 2
6. Closure
- Close the plantar and dorsal flaps over the bone end without tension
- Use absorbable sutures for deep tissues and non-absorbable sutures for skin
- Ensure the plantar flap provides adequate padding over the amputation site
- Consider leaving the wound open if significant infection is present 2
7. Dressing and Immobilization
- Apply a sterile, non-adherent dressing
- Consider a bulky protective dressing or splint to immobilize the foot
- Elevate the foot to reduce postoperative edema
Postoperative Care
- Monitor for complications including wound issues and infection 1
- Implement appropriate wound care protocol
- Provide pressure offloading to prevent recurrent ulceration 2
- Evaluate foot biomechanics and consider therapeutic footwear 2
- Plan for comprehensive rehabilitation to optimize functional outcomes 1
Special Considerations
- In diabetic patients, hallux interphalangeal joint arthroplasty may be considered as an alternative to amputation for chronic ulcerations 3
- Be aware that great toe amputation is associated with altered weight-bearing distribution of the foot 4 and may predict future limb loss 5
- Consider the long-term functional implications, as approximately 60% of diabetic patients may require a second amputation within 10 months of the initial procedure 6
By following these systematic steps and considering the specific needs of each patient, surgeons can optimize outcomes following great toe amputation while preserving maximum function.