Overview
Amputations around the foot and ankle account for a growing share of lower-extremity amputations. Indications are peripheral vascular disease, neuropathy, infection, trauma and tumor. When limb salvage is not in the patient's best interest, amputation or disarticulation should be regarded as a reconstructive procedure rather than a treatment failure, while recognizing the high morbidity and mortality of nontraumatic amputations. (Campbell)
Indications and Patient Selection
The LEAP study found injury severity scores unhelpful for deciding who benefits from amputation, but the Mangled Extremity Severity Score was highly specific for identifying patients who do not need amputation. The OUTLET study found little benefit of limb salvage over initial amputation in complex distal tibial, ankle and hindfoot trauma. (Campbell)
Diabetic patients make up a large share of foot amputations, and up to 30% progress to a more proximal level. Almost half of patients with a hindfoot ulcer progress to below-knee amputation or higher. Patients with diabetes fear major amputation more than death, less so for partial foot amputation, so compassion and education are essential. (Campbell)
Optimize healing before surgery: assess perfusion, nutritional status (including in patients with a high BMI) and glycemic control. A higher-level amputation may be chosen if delay carries unacceptable risk. (Campbell)
Healing predictors for toe, ray and partial foot amputations: toe pressure above 45 mm Hg and transcutaneous oxygen above 37 mm Hg correlate with healing, and transcutaneous oxygen below 20 mm Hg makes healing unlikely. (Campbell)
Optimizing Outcomes (Campbell)
Handle skin edges gently without forceps pressure, keep flaps thick, avoid a tourniquet, control hemostasis and avoid hematoma (often a problem in anticoagulated patients).
For midfoot and forefoot ulceration, assess ankle dorsiflexion and have a low threshold to lengthen the Achilles.
Advancement, rotation, transposition and pedicle flaps cover limited defects; free flaps are often needed for larger ones. Involve plastic surgery early.
Negative-pressure dressings heal diabetic wounds proximal to the transmetatarsal level faster and more predictably than moist gauze, but help less in small forefoot wounds or severe vascular disease. A multidisciplinary team, with orthotist and prosthetist input, is beneficial.
Functional Consequences of Toe Amputation (Campbell)
Loss of a single toe causes little disturbance. Loss of the great toe does not affect normal-pace walking but produces a limp at rapid gait or running because push-off is lost.
Second toe amputation may lead to progressive hallux valgus (about 70%) or ulceration of the first or third toe. A Lapidus procedure to narrow the forefoot may reduce this risk.
Loss of all toes is tolerated in slow walking but disabling in rapid gait and in squatting or tiptoeing. Removal of more than two rays is often more disabling than a transmetatarsal amputation.
Technique 17.1: Terminal Syme Amputation of the Hallux (Campbell)
Indications: hallux terminal ulceration, tuft osteomyelitis, nail bed injury at the tip, and recalcitrant ingrown nail or nail deformity.
Palpate the hallux interphalangeal joint and mark a transverse dorsal incision just distal to it. A digital tourniquet is usually unnecessary.
Extend the incision on both sides of the nail bed to include the eponychium and curve it distally to create a plantar flap.
Remove the nail plate, nail bed, germinal matrix, contiguous soft tissue and the distal part of the distal phalanx, keeping the insertions of the extensor and flexor hallucis longus.
Close the skin in one everted layer without trimming skin tags, which remodel.
Apply a mildly compressive forefoot dressing.
Aftercare: sterile dressing for 2 weeks, sutures out at 12 to 16 days, weight bearing in a stiff-soled shoe until healed, then a wide toe box shoe.
Technique 17.2: Amputation at the Base of the Proximal Phalanx (Campbell)
Keeping the proximal phalanx base is often preferable to MTP disarticulation. In the hallux, 1 cm of proximal phalanx preserves flexor hallucis brevis and plantar fascia contributions, and it may slow drift of adjacent toes.
Great toe: long medial incision circumscribing the digit, with a plantar flap slightly longer than the dorsal. Lesser toes 2 to 4: short dorsal racquet incision starting 1 cm proximal to the MTP joint. Fifth toe: lateral incision continued around the medial side to the PIP level.
Osteotomize the proximal phalanx 1 cm from its base, preserving the brevis tendon attachments.
Pull the extrinsic tendons distally, divide them and let them retract.
Divide the digital nerves proximal to the bone end; divide and ligate the digital vessels.
Irrigate, obtain hemostasis and close the skin (interrupted nonabsorbable sutures for toes 2 to 4).
Aftercare: sterile dressing 12 to 16 days; sutures in dysvascular limbs out at 21 to 23 days unless healed sooner. A cut-out toe box or wooden-soled shoe is worn until suture removal. Protected weight bearing is usually unnecessary.
Techniques 17.3 and 17.4: MTP Joint Disarticulation (Campbell)
In the diabetic foot, ischemia or osteomyelitis is the main indication.
Fashion a long plantar and short dorsal flap and dissect them to the level of bone section.
Incise the dorsal capsule with the toe flexed, then the rest of the capsule after dividing the flexor tendons and neurovascular bundles. Divide the bundles distal to the bifurcation so adjacent digits are not jeopardized.
Divide the tendons and let them retract, smooth the bone end with a rasp, and close the flaps.
In the insensate foot, remove the sesamoids when disarticulating the hallux, staying close to the periosteum.
Technique 17.5: First or Fifth Ray (Border Ray) Amputation (Campbell)
Base the incision medially for the first ray or dorsolaterally for the fifth, from the midline of the metatarsal eminence plantarward to about mid-metatarsal level. With deep infection such as diabetic osteomyelitis, take the incision to bone because a thin flap may not survive.
Raise dorsal and plantar full-thickness flaps to the metatarsal, open the capsule and complete the disarticulation, then cauterize the neurovascular bundles.
To remove part or all of the metatarsal, extend the incision along the shaft, raise flaps at bone level and cut the first metatarsal from proximal plantar-medial to distal dorsal-lateral (the fifth in the mirror direction). Disarticulating the MTP joint first makes removal easier.
At the medial cuneiform, try to preserve the penetrating branch of the dorsalis pedis and consider reattaching tibialis anterior if detached (it may stay on the cuneiform). Peroneus longus reattachment is not necessary.
In the fifth ray, preserve the base to keep peroneus brevis attached; if the whole bone is removed, reattach the brevis locally or tenodese it to the peroneus longus.
Close in a single layer of nonabsorbable suture. Aftercare matches Technique 17.2.
Multiple and Central Ray Amputation (Campbell)
If more than two rays (especially medial) must go, a transmetatarsal amputation is usually more functional, although preserving the medial two rays, even with a free flap, may improve ambulation. Partial foot amputations are desirable when the opposite foot is at high risk.
Second ray removal: consider a Lapidus-type procedure to prevent severe valgus. If the third and fourth rays are removed, an osteotomy of the fifth metatarsal base can ease closure.
Technique 17.6: dorsal longitudinal incision over the ray (between metatarsals if two are removed); disarticulate the MTP joint first; remove the intrinsic muscles, cut the metatarsal and lift it from proximal to distal; section the bone from dorsal-distal to plantar-proximal to avoid pressure points. If the wound is not surgically clean, leave it open and inspect at 48 to 96 hours, then close primarily or graft. Protected weight bearing for 3 to 4 weeks.
Deep central space abscess: debride necrotic intrinsic muscle and excise one or more central rays. With compromised vascularity, edema or incomplete debridement, use retention sutures to approximate the foot borders loosely so the wound can drain, and consider negative-pressure therapy.
Transmetatarsal Amputation: Key Points (Campbell)
Allows walking with a shoe filler and steel shank with rocker sole, without a prosthesis, and preserves limb length. Healing is less predictable than transtibial amputation, so the patient must accept possible revision.
Indications: deep infection, chronic ulceration or gangrene involving multiple digits or dorsal forefoot skin, and unsalvageable forefoot crush. Contraindications: poor vascularity, deep infection tracking proximal to the forefoot, and unwillingness or inability to undergo revision. Pedal arch patency is associated with healing.
Achilles lengthening or gastrocnemius recession is almost always warranted, done first, to prevent equinus and terminal stump pressure. Preserve essentially all plantar skin proximal to the MTP joints for a long plantar flap.
Complications
Wound breakdown from hematoma, ischemia or tension; infection; progression to a more proximal amputation; hallux valgus or ulceration after second toe loss; equinus after transmetatarsal amputation. (Campbell)
References
Richardson DR. Amputations of the foot. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 17.