Primary Surgery Vol.2 – Trauma: AMPUTATING THROUGH THE FOOT AND TOES

AMPUTATING THROUGH THE FOOT AND TOES

METATARSAL AMPUTATION

INDICATIONS (1) Crush injuries of the patient’s toes. (2) Occasionally, in leprosy when there are large and persistent ulcers due to osteitis. (3) Gross infections presenting late with osteitis.

CONTRAINDICATIONS The risk of failure is considerable if his toes are gangrenous, particularly if he is diabetic.

METHODS For the general method see Section 56.1. Make a long plantar and a short dorsal flap, as in Fig. 56-15. This will bring the suture line dorsally.

Start the dorsal incision at the site of bone section on the anteromedial aspect of the patient’s foot. Curve it distally a little to reach the midpoint of the lateral side of his foot. Take the plantar incision distally beyond his metatarsal heads 1 cm proximal to the crease of his toes. The foot is thicker medially, so make the flap slightly longer on the medial than on the lateral side.

Cut the plantar flap to include his subcutaneous fat and a thin bevelled layer of his plantar muscles. Reflect the plan tar flap proximally to the site of bone section and then use large bone cutters to divide his metatarsals. Find the nerves and cut them well proximally. Pull the tendons and cut them so that they retract into the stump of his foot.

Release the tourniquet, control bleeding, drain and close the stump as usual (56.1).

AMPUTATING AT THE BASE OF A PROXIMAL PHALANX

The big toe Make a long posteromedial flap. Start the incision at the base of the patient’s big toe in the midline dorsally. Curve it distally over the medial side of his toe for a distance slightly greater than its dorsoplantar diameter. Then bring it proximally across the plantar surface. Section his flexor and extensor tendons and suture them together over the end of the bone to maintain the position of the sesamoids under the head of his first metatarsal.

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Figure 56.16: TOE AMPUTATIONS. A, avoid amputating the second toe if you can. B, amputating the big toe. C, the incision for amputating the 3rd toe. D, amputating the stumps of the last four toes. Partly from Techniques Elementaires pour Medecins Isolé, with kind permission.

Alternatively, some surgeons make a ’V’ or a ’Y’ on the medial side of the foot.

Second toe.

Avoid amputating this.

The remaining toes.

Make a short dorsal racquet incision, proceed as in the corresponding amputation in the hand.

PLAN FLAPS LONG, YOU CAN ALWAYS SHORTEN THEM LATER