If the surgeon chooses a guillotine amputation, a circumferential skin incision is made distally to the site of disarticulation.
Measure the digit diameter at the level of disarticulation.
A circumferential incision is ideally made at least 0.5 toe-diameter distal to the disarticulation site to ensure sufficient soft tissue for tension-free closure.
Tension-free closure may be difficult to achieve with distal injuries because of the nail or the lack of viable soft tissue. In this case, the nail must be removed before closure, or the amputation will need to be performed at the next proximal joint.
Amputation with extended plantar flap for reconstruction
If an extended plantar flap is selected, the surgeon should aim to use more plantar than dorsal skin for the closure.
The length of the plantar flap will need to be at least the diameter of the wound at the level of the amputation.
The digital neurovascular bundle is identified, ligated (cauterized), and transected.
The extensor tendons are transected.
The collateral ligaments are divided.
Distraction across the joint will allow visualization of the deeper structures. The plantar plate, flexor tendon(s), and skin are divided, preserving an adequate plantar flap.
The divided flexor tendon is tenodesed to the intact plantar plate or allowed to retract.
Remove the digit.
Irrigate the area and confirm hemostasis.
The wound is closed in layers. Resorbable sutures may be used in the deep dermal tissues, followed by skin sutures.
The amputation site must be protected until the soft tissues are healed. We recommend a flat, rigid sole shoe.