Lower Extremity Amputations

Toe & Ray Amputation

• Toe Amputation

  • indications: lesions to the middle and/or distal phalanges

  • technique

    1. incise skin & soft tissue using a "tennis racket" incision

       • achieves tension-free closure

       • "handle" lies longitudinally along dorsal surface

         • midline for digits 2, 3, & 4

         • away from midline for digits 1 & 5

    2. divide tendinous attachments at level of skin incision

    3. trim back bone accordingly

    4. use a #15 blade to disarticulate the joint capsule

    5. excise cartilage w/a rongeur & file bone edges smooth

    6. avoid excessive monopolar energy

    7. close w/interrupted non-absorbable monofilament suture in 1 layer

• Ray Amputation

  • indications: lesions to the proximal phalanx

  • technique

    1. incise skin & soft tissue using a "tennis racket" incision

       • achieves tension-free closure

       • "handle" extends proximally to metatarsal head

    2. divide tendinous attachments at level of skin incision, allow to retract

    3. transect metatarsal head before dividing remaining soft tissue

    4. excise sesamoid bones & flexor tendons on tension (allow residual tendon to retract)

    5. excise cartilage w/a rongeur & file bone edges smooth

    6. avoid excessive monopolar energry

    7. close w/interrupted non-absorbable monofilament suture in 1 layer

  • 1st ray amputations are prone to recurrent ulceration in 60% of patients (consider TMA vs 1st ray amputation)

Trans-Metatarsal Amputation (TMA)

• indications: wounds of entire forefoot or when multiple ray amputations are considered

• technique

  1. incise transversely over foot dorsum at level of distal metatarsals, come to corners

     • medially at 1st metatarsal head

     • laterally at 5th metatarsal head

  2. extend incision from corners onto plantar surface across base of toes

  3. divide extensor tendons at skin level & incise periosteum

  4. divide metatarsals w/bone saw, each ~3 mm shorter than last moving laterally

  5. divide plantar myofascial attachments to metatarsal heads

Midfoot & Hindfoot Amputation

1. Lisfranc tarsometatarsal disarticulation

2. Chopart midfoot amputation

3. Syme amputation

Below-Knee (Trans-Tibial) Amputation (BKA)

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Through-Knee Amputation

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Above-Knee (Trans-Femoral) Amputation (AKA)

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Hip Disarticulation

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Trans-Pelvic Amputation (Hemipelvectomy)

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