Amputations Pathway Updated: 10/4/2016

Midfoot Amputation

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TECHNIQUE STEPS
Preoperative Patient Care
Operative Techniques
E

Preoperative Plan

1

Radiographic templating

2

Execute surgical workthrough

  • describes the steps of the procedure to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
F

Room Preparation

1

Surgical instrumentation

  • basic major orthopedic set
  • oscillating saw
  • amputation knife
  • silk free and stick ties
  • suction drain

2

Room setup and equipment

  • standard OR table
  • fluoroscopy

3

Patient positioning

  • place patient supine
  • place small bump under ipsilateral hip to internally rotate the leg
  • place a thigh tourniquet
G

Superficial Dissection

1

Trace the dorsal and plantar skin flaps

2

Make the skin incision

  • make a skin incision starting at the dorsomedial aspect of the foot at the midshaft level of the first metatarsal
  • continue the incision in a transverse manner along the dorsal aspect of the foot along the midshafts of the 2nd,3rd and 4th metatarsals
  • end the incision over the dorsolateral aspect of the midshaft of the 5th metatarsal

3

Continue incision medially

  • start incision from the medial aspect of the dorsal incision and continue it down to the level of the first metatarsal head

4

Make lateral incision

  • start incision from the lateral aspect of the dorsal incision and continue it down to the level of the first metatarsal head

5

Join incisions

  • curve both incisions in a plantar fashion
  • make a transverse incision on the plantar surface along the metatarsal heads
H

Deep Dissection

1

Dissect through underlying fascia

  • dissect through the subcutaneous tissue

2

Identify the neurovasculature

  • identify the dorsalis pedis artery and ligate
  • identify the peroneal and posterior tibial nerves
  • place gentle traction and resect nerves using sharp dissection
  • this prevents postoperative neuromas

3

Identify tendons

  • identify the flexor and extensor tendons of the foot
  • pull distally and perform sharp transection

4

Expose bone

  • use sharp dissection to create myocutaneous skin flaps

5

Maintain flaps

  • use an elevator to reflect tissues from the metatarsals proximally
  • reflect back to the level of the metatarsal shafts
  • make sure that the plantar flap is longer than the dorsal flap
I

Resect Bone

1

Resect metatarsal heads

  • use a small oscillating saw and transect heads at the level of the dorsal skin incision
  • transect the metatarsal heads in a dorsal distal to proximal plantar direction
  • preserve the peroneus brevis when resecting the 5th metatarsal head
  • bevel the resected ends of the 1st and 5th metatarsals
  • bevel medially and laterally
  • this is done to prevent skin ulcerations
J

Wound Closure

1

Prepare Flap

  • use sharp dissection to debulk the plantar flap

2

Irrigation, hemostasis and drain

  • irrigate with pulse irrigation
  • place drain

3

Deep closure

  • 0-vicryl for deep fascia
  • subcutaneous with 2-0 vicryl

4

Superficial closure

  • skin closure with 3-0 nylon (vertical/horizontal mattress)
  • soft incision dressing well padded to reduce pressure in incision
Postoperative Patient Care
 

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