Amputations of the toes and metatarsals are a practical means to resolve both simple and complex foot pathology. Infection, vascular insufficiency, neoplasm, nonsalvageable trauma, musculoskeletal deformity, and pain are the most frequent indications for such amputations. Globally, foot complications associated with diabetes are the most common cause of foot amputations; many are preceded by ulcerations of the feet and toes. More than 50% of foot ulcerations will lead to bone and soft tissue infections. Vascular surgeons are frequently consulted for both elective and emergent surgical amputation by a variety of care providers. Vascular surgeons are most often called upon to assess and improve circulation, when indicated, in patients with peripheral artery disease and/or diabetes who present with a wound infection +/− and a spectrum of limb-threatening ischemia. Depending on practice patterns, and whether a comprehensive limb salvage service is present, vascular surgeons may also provide amputation services in such patients. Familiarity with the indications and performance of the most commonly performed forefoot amputations is therefore vital to the limb salvage surgeon.

Adequate resection of soft tissue and bone is the treatment of choice for malignant neoplasms and infections. Musculoskeletal biomechanics also play an important role in the decision for amputation selection, and in some cases could influence the decision between isolated ray resection and transmetatarsal amputation (TMA). Lower extremity amputation is often followed by rehabilitation and provision of custom footwear. In combined multispecialty limb-preservation teams, vascular surgeons will often make critical decisions about what level of amputation is likely to heal and optimize outcome. Similarly, podiatric and orthopedic surgeons make critical decisions regarding ability to achieve or maintain functional ambulation, biomechanical stability, and rehabilitation.

Most amputations are elective or semielective in nature; risks are markedly elevated when amputations must be performed urgently or emergently, usually in patients with diabetes in the setting of advanced infection. In such urgent settings, open management of infection and trauma is often indicated with definitive closure deferred until after the patient and the limb have been stabilized. Relative contraindications for elective amputation would include inadequate blood supply at the proposed level of amputation, inadequate soft tissue for coverage without a subsequent viable plan for reconstruction, and the inability to obtain a functional result in a given patient for an amputation at that level.

Surgery involving soft tissue and bone of the lower extremity merits antibiotic prophylaxis as well as possible anticoagulation prophylaxis 30 to 60 minutes before incision. Prophylaxis against gram-positive organisms is empirically administered, most often with cefazolin. Clindamycin may be used in the presence of a penicillin allergy. Skin preparation is best performed with chlorhexidine scrub detergent to remove debris and lower bacterial colonization.

Many of these procedures can be performed with standard surgical instruments and dissection scissors. Scalpel blades no. 15 and no. 10 serve well for toe and metatarsal level amputations respectively. Sistrunk and Mayo scissors are, by design, useful in transecting joint capsules, plantar plates, and tendons within the forefoot. Periosteal elevation can be simply performed with either Freer or small Key elevators. Bone resection can be performed with bone cutters as well as a Rongeur bone debridement instrument. Metatarsal level bone resection merits use of a powered sagittal saw.

Recommended adjunctive instruments to improve exposure include skin hooks, Ragnell retractors, Senn retractors, McGlamry elevators, small Hohmann retractors, Weitlaner self-retaining retractors, and Gelpi retractors. Coker, Lahey, and small towel clamps are useful to grip loose fragments of bone within an incision. Examples of optimal use of these instruments will be further discussed below.

The use of a tourniquet may reduce the ability of small vessel bleeding to be identified intraoperatively, therefore we generally do not routinely use tourniquets on these cases as bleeding can be more controlled with appropriate surgical technique. If a tourniquet is used to facilitate intraoperative visualization, it should be released prior to closure to allow for hemostasis.

Resection of remaining joint capsule, fascia, ligaments, and tendons should also be performed. In the presence of soft tissue contamination and infection, these tendon sheaths have been shown to promote the spread of bacteria. Synovial tissue such as sheaths and joint capsules can continue to excrete synovial fluid, which inhibits healing of wound edges and delays granulation tissue.

The procedures described involve the forefoot and a supine position is recommended. Many patients have a natural external rotation from contracted hip muscles, and it is thus recommended that a bump or hip roller to be placed under the bed padding or mattress, corresponding to the ipsilateral hip or buttock. The patients’ heel should be at the most inferior aspect of the operating table to allow visualization and manipulation of the entire circumference of the forefoot. It is also advisable to have the table raised and tilted into a reverse Trendelenburg position to avoid postural strain on the surgeon and assistants.

A variety of digital and metatarsal procedures exist for salvage and amputation strategies. Many of these are described in relation to infection control in neuropathic and diabetic patients, but are readily applicable to the other indications for amputation mentioned. The passages that follow will describe techniques for the following:

This technique is commonly used to remove an infected distal toe. Because the flexor digitorum longus insertion is compromised in this process, a hammered toe contracture is often alleviated, as a result.

The incision of choice for this amputation is circumferential at the level of the distal or proximal interphalangeal joint. This incision is usually elliptical rather than circular and carried more distal than the joint, as it becomes plantar, in order to provide a short, plantar, “fish-mouth” flap. Interrupted skin sutures are often adequate for closure. If difficulty is experienced with wound closure, resection of the phalangeal head will often afford flap closure without excessive tension.

This is an effective way to remove a toe that is significantly involved with disease, while maintaining an illusion of a normal appearance. The elliptical fish-mouthed incision described above is, once again, useful in providing closure of this amputation. It is advisable to resect the phalangeal head proximal to the condyles, at the narrower neck region. This technique will reduce bulk and edge loading of the remaining bone and reduce the complications of dehiscence and re-ulceration.

For instances in which the extent of amputation and bone resection is uncertain at the onset of the operation, it is useful to utilize the dorsal “racket-handle” type incision. This approach provides generous bony exposure and makes it easier to obtain proximal clean margins. Closure is then performed in vertical linear fashion.

Arthroplasty is another digit-sparing procedure to remove bone and often increase range of motion at the level of a particular joint. Digital contracture is a common predisposing factor to the development of wounds on the distal aspect of the toe as well as the dorsal aspect of the proximal interphalangeal (PIP) joint. Commonly, infection of the interphalangeal joint will result from such wounds, particularly in patients with diabetes.

When considering clinical scenarios in which patients are reluctant to lose a toe, this technique can offer an alternative solution to infections of the middle digit. A dorsal linear incision offers adequate exposure for resection of the phalangeal head or, in some more extreme conditions, a bipolar resection of the phalangeal head and adjacent phalangeal base will avoid having to amputate the entire digit.

This technique is particularly useful for wounds/ulcers of the mid-hallux. Pressure-related wounds on the plantar aspect of the great toe can often be surgically offloaded and healed by an interphalangeal arthroplasty or a Keller (phalangeal base resection). A Keller arthroplasty effectively decompresses the respective joint and affords the patient greater range of motion within the foot during ambulation, thereby decreasing plantar pressures and expediting wound healing.

In instances where preservation of the digit is not possible, disarticulation at the level of the metatarsal-phalangeal joint (MTPJ) is useful. The surgical incision is made just beyond the junction of the toe and distal skin of the foot. A full-thickness dissection can be performed. Use of high leverage dissection scissors (i.e., Sistrunk) will help to transect capsule and plantar plate of the digit, as well as the accompanying tendons.