Toe Amputation - Indication, Contraindications, and Procedures

What Is Toe Amputation?

Toe amputation is a common surgical procedure involving the removal of one or more toes from the foot, generally performed by general or orthopedic surgeons. The main aim of the procedure is to remove part or all of a toe that is causing any issues and provide relief from pain in the toe or foot or pressure caused by the toe on the other toes and footwear.

It is performed for a wide variety of medical conditions; one of the common indications is in patients with diabetic foot. This procedure is considered only when conservative treatments fail to cure the medical conditions affecting the toes. Before performing the surgery, systemic conditions such as diabetes and hypertension should be treated, as they affect the blood vessels and nerves.

The type of toe amputation and the extent of the amputation depends on the anatomy and severity of the condition. With any type of amputation, there will be a certain degree of functional loss, depending on the amount of tissue amputated.

What Are the Indications for Toe Amputation?

The indications for toe amputation are classified based on the following:

• Dead - In a dead toe, the blood supply to the toe will be completely compromised, which may lead to infarction and necrosis (death of the tissue). This may cause the toe to turn dry, black, and non-functional. This condition is often noted in conditions like severe, uncontrolled diabetes due to vascular disease. Smoking, hyperlipidemia, hypertension, narrowing or spasm of blood vessels, or severe frostbite are other causes of peripheral vascular disease, causing tissue death.

• Deadly - This category is very dangerous; if prompt management is not provided, it can even cause death. This is because the disease can result in systemic sequelae. Large limb segments affected by wet gangrene and malignancy are some examples.

• Dead Loss - A toe is considered dead loss when it is diseased to an extent where it is not treatable and is no longer functional.

What Are the Contraindications for Toe Amputation?

The main contraindication for toe amputation includes:

• Poor demarcation and patchy gangrene dead tissues. If the borders of the dead tissue are unclear, it may be difficult to understand the true extent of the disease, and so the surgeons cannot be certain about amputating.

• If amputation results in a reduced quality of life and a limited life expectancy, then the amputation is contraindicated.

How Is Toe Amputation Performed?

• Before the procedure, adequate anesthetic is given to the patient, and the surgeons create a sterile field for good access to the affected foot.

• Appropriate incision lines are marked on the skin for the amputation.

• A flap is collected for amputational closure. A dorsal flap, a plantar-based flap, a side-to-side flap, or a fish-mouth flap is chosen for a partial toe amputation. For a transmetatarsal or disarticulation amputation, a long plantar flap is chosen.

• The necrotic tissues are removed completely.

• Proper drainage should be done in cases of infection, and the sample should be sent for culture and sensitivity testing.

• The blood vessels are ligated or cauterized.

• If the wound is not closed, proper dressing is done by loosely packing the wound with gauze soaked in saline or povidone-iodine.

What Is the Type of Toe Amputation?

• Partial Toe Amputation - In partial toe amputation, only a portion of the toe is amputated. It is usually performed to remove diseased or damaged tissue while preserving as much healthy tissue as possible. Even a specific part of the toe, such as the tip or a segment, can be removed in partial toe amputation, depending on the extent of the diseased or damaged tissue.

• Disarticulation of Toe -In this type of amputation, the distal segment is removed. After removing the segment, a burr, or curette, is then used to remove the cartilage from the remaining joint surface, as this can help in healing. Finally, the suture is done.

• Ray Amputation - Depending on the severity of the condition, the amputation may range from a single toe removal and its metatarsal to the removal of the entire lateral four toes and their metatarsals. This type of amputation is generally indicated when multiple toes in the same region are affected, and removing them along with a portion of the metatarsal bone is necessary.

• Transmetatarsal Amputation - Transmetatarsal amputation involves the removal of the entire toe along with a portion of the metatarsal bone. This type of amputation is indicated in cases of gangrene, trauma, or other pathology, is confined only to the toes, and does not involve the web spaces or the forefoot. It is a more extensive amputation than a ray amputation and is considered when multiple toes and the surrounding tissues are involved. It requires a plantar flap to close the wound, and regular wound irrigation is also needed.

What Is Post-operative Care After the Toe Amputation Surgery?

Following the surgery, patients are closely monitored in the hospital to check for any side effects from surgery or anesthesia and to ensure proper wound healing. Pain medication may be prescribed to help alleviate the pain and discomfort. The hospital stay may depend on the individual and any complications.

The following factors should be considered after a toe amputation:

• Elevation - After surgery, the foot will be kept elevated as it helps to reduce swelling.

• Walking - When the wound begins to heal, healthcare professionals may recommend the patient start walking with a physical therapist's help.

• Rehabilitation - Some toe amputation patients require a rehabilitation program to follow at home. Physical therapy plays an important role in rehabilitation by aiding patients to adapt to changes in gait, balance, and overall foot function. Also, the therapist may recommend some exercises to strengthen the surrounding muscles and improve joint mobility.

• Proper Monitoring - After the surgery, proper monitoring is required to check for signs of infection, swelling, bleeding, increased pain, or decreased sensation in the toes or footrest.

Conclusion

Toe amputation is a surgical procedure done when all the traditional management fails to preserve the toe, and when removed, it can improve the patient's overall health. This procedure is indicated for conditions like diabetic foot, trauma, frozen bite, and gangrene. Following the procedure, proper care is crucial to avoid any complications. With advancements in surgical techniques, rehabilitation, and prosthetic options, toe amputation can significantly improve the overall quality of life for the patient.