Toe Amputation

Updated: Jun 02, 2016
  • Author: Adam Frankel, MBBS, PhD; Chief Editor: Erik D Schraga, MD  more...
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Overview

Background

Toe amputation is a common procedure performed by a wide variety of health care providers. The vast majority of toe amputations are performed on patients with a diabetic foot. [1] Although regional variation is noted, most of these procedures are done by general, vascular, and orthopedic surgeons (particularly those subspecializing in foot and ankle surgery); in some countries, podiatrists are involved.

There are three broad indications for amputation of any body part, as follows (see Indications) [2] :

  • Dead
  • Deadly
  • Dead loss

Before any amputation, the clinician should ensure that the patient’s medical circumstances have been optimized (ie, should "reverse the reversible"). With impending toe amputation, this step encompasses such measures as glycemic control and consideration of revascularization when severe macrovascular disease is contributing to ischemia.

The method of toe amputation (disarticulation vs osteotomy) and the level of amputation (partial or whole phalanx vs whole digit vs ray) depend on numerous circumstances but are mainly determined by the extent of disease and the anatomy. With any amputation, the degree of postoperative functional loss is generally proportional to the amount of tissue taken. The great toe is considered the most important of the toes in functional terms. Nevertheless, great-toe amputation can be performed with little resulting functional deficit. [3, 4]

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Indications

A “dead” toe is one in which the blood supply is so completely impeded that infarction and necrosis develop (see the images below). Infarction results in dry gangrene, with nonviable tissue becoming dry and black in color (because of the presence of iron sulfide, a product of the hemoglobin released by lysed erythrocytes).

Gangrenous fifth toe. Dubious perfusion in fourth Gangrenous fifth toe. Dubious perfusion in fourth toe.
Lateral two toes for amputation (lateral view). Lateral two toes for amputation (lateral view).

In Western societies, a “dead” toe is most commonly seen as a complication of diabetes mellitus and is due to a combination of macrovascular and microvascular disease. Other major risk factors for peripheral vascular disease (as for all atherosclerotic diseases) include smoking, hypertension, and hyperlipidemia. Rarely, pathologic processes confined to the microvasculature are to blame (eg, thromboangiitis obliterans [Buerger disease], vasospastic diseases, severe frostbite).

The “deadly” category generally refers to a more proximal disease processe that can result in systemic sequelae. For example, a large limb segment affected by wet gangrene (with macroscopic putrefaction and surrounding cellulitis) can be deadly if not addressed urgently. Malignancy may also necessitate amputation, though infrequently.

A toe is a “dead loss” when it is diseased to the point where it is irreparable (as with chronic osteomyelitis), it ceases to be functional (as with significant trauma), or it is impeding function (as with neuropathic pain).

Cases in which ray amputation has been performed to treat foot macrodactyly in children have also been described. [11]

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Contraindications

The main contraindication for toe amputation is poor demarcation of infarcted tissue (patchy gangrene). If the borders of the infarcted area are unclear, the surgeon cannot know the true extent of the disease and hence cannot be certain of amputating to a region of adequate blood supply.

More broadly, amputation of any body part is contraindicated when it will result in a reduced quality of life in the setting of a limited life expectancy. However, this contraindication is not usually relevant to toe amputation.

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Technical Considerations

Anatomy

The phalanges of the foot correspond, in number and general arrangement, with those of the hand; two are found in the great toe, and three are found in each of the other toes. However, the phalanges of the foot differ from the phalanges of the hand in terms of size, with the bodies of the phalanges of the foot being much reduced in length and, especially in the first row, laterally compressed.

The body of each proximal phalanx is similar to the metatarsals in being convex above and concave below. The base is concave for articulation with the respective metatarsal, and the head presents a trochlear surface for articulation with the second phalanx.

For more information about the relevant anatomy, see Foot Bone Anatomy.

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