Toe Amputation Periprocedural Care

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

Patient Education and Consent

Prevention and early detection of future disease should be discussed with the patient. Education on pressure-area pathogenesis is important as part of a strategy to encourage the patient to prevent further problems. Daily self-inspection aids in early detection of recurrent episodes. Regular visits with a podiatrist should be encouraged to ensure that shoes are well fitted. Thick cotton socks help to prevent pressure areas, and enclosed shoes act as a barrier to the entry of foreign bodies. Informed content must be obtained.

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Preprocedural Planning

Antibiotics should be considered in accordance with the individual patient’s circumstances and local guidelines. Australian recommendations for perioperative antibiotics include the following options:

  • Cefazolin 1 g intravenously (IV) at induction or
  • Benzylpenicillin 1.2 g IV at induction followed by 1.2 g every 6 hours for 24 hours or
  • Metronidazole 500 mg IV at induction followed by 500 mg every 12 hours for 24 hours

Similarly, deep vein thrombosis prophylaxis should be considered in accordance with both patient factors and local guidelines.

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Equipment

The materials required for toe amputation include the following:

  • Indelible pen
  • Povidone-iodine, chlorhexidine, or a similar surgical disinfectant
  • Scalpel with No. 15 blade
  • Toothed forceps
  • Skin hooks/rakes
  • Bone cutter
  • Bone nibbler
  • Curette
  • Diathermy
  • Dressings (including gauze soaked with povidone-iodine)

Additional equipment may be needed, depending on the exact method used, but such equipment usually is readily found on a general surgical tray.

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Patient Preparation

Anesthesia

Many options are available for anesthesia. However, the usual patient has significant medical comorbidities, and these should be considered carefully in the context of anesthesia.

Because of the high prevalence of diabetes mellitus in patients undergoing toe amputation, anesthesia requirements may actually be minimal as a result of peripheral neuropathy. Local anesthesia alone is often satisfactory, either in the form of a ring block or a regional (usually ankle) block. Spinal or epidural anesthesia can also be used, although the use of antiplatelet or anticoagulant medications in this population is frequent. General anesthesia may also be feasible.

Positioning

Toe amputation is best performed with the patient in the supine position.

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Monitoring and Follow-up

Adequate postoperative analgesia must be ensured, though the requirement is often minimal as a result of peripheral neuropathy.

The minimal pain usually experienced postoperatively often allows early mobilization. Some authors caution against mobilization if cellulitis is present. [2] As the patient begins to mobilize, both feet should be observed (particularly in the diabetic patient) for the development of new pressure areas. Such pressure areas may develop as a result of alteration of the remaining ipsilateral foot architecture (depending on the type of amputation performed) or subtle changes in gait that affect the contralateral foot.

Dressings should be inspected regularly and changed as required.

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