- Preoperative assessment
- Vascular status evaluation
- Doppler or angiography to assess inflow; adequate perfusion is required for healing
- Control of infection and metabolic optimisation
- Optimise diabetes and nutrition; treat sepsis if present
- Mark level of amputation
- Aim to preserve maximal length without compromising soft tissue viability
- Vascular status evaluation
- Anaesthesia and positioning
- Regional block or general anaesthesia
- Supine position with foot elevated
- Tourniquet may be used
- Incision and dissection
- Elliptical fish-mouth incision
- Dorsal incision over metatarsal heads, plantar flap extended distally
- Plantar flap is thicker and provides durable coverage
- Dissect through subcutaneous tissue preserving as much viable tissue as possible
- Divide extensor tendons and capsule at MTP joints
- Expose metatarsal necks and disarticulate at MTP joints or resect through metatarsal shafts
- Elliptical fish-mouth incision
- Bone handling
- Saw metatarsals transversely or in slight curve (dome-shaped)
- Remove sharp edges with rongeur or rasp to avoid pressure points
- Saw metatarsals transversely or in slight curve (dome-shaped)
- Tendons
- Trim back flexor tendons
- Closure
- Irrigate thoroughly
- Close deep tissue without tension
- Plantar flap folded over distal ends and sutured with 2-0 vicryl
- May place drain if high risk of seroma/haematoma
- Skin with 2-0 Nylon
- Apply sterile dressing and splint or cast to offload
- Postoperative care
- Elevate limb to reduce oedema
- Monitor for infection or dehiscence
- Delayed weight bearing until healing is confirmed (2-3 weeks)
- Orthotic or prosthetic support needed for gait balance
- Complications
- Wound breakdown or infection
- Equinus deformity
- Stump pain or ulceration
- Need for higher-level amputation if healing fails
https://www.youtube.com/watch?v=5XCWx8Q3G8Y&ab_channel=Dr.GennadyKolodenker%2CDPM