Guillotine Ankle Amputation

Guillotine amputations are performed either for speed or for control of infection before a second, definitive amputation. In guillotine ankle amputation, all of the tissues from the skin to the bone are cut at the level of the ankle without creating flaps of soft tissue.

Amputation surgery can be definitive if the wound flaps created at the stump can be approximated and no further surgery is anticipated to close the end of the stump. A guillotine amputation, by definition, leaves an open wound at the end of the stump. A further surgical procedure planned as a second stage involves a higher-level amputation to create soft-tissue flaps and provide skin cover over the open end of the stump.

This article describes the circumstances and technique of performing a guillotine amputation at the level of the ankle joint.

A guillotine ankle amputation is indicated in the presence of severe infection or necrosis in the midfoot or hindfoot, such as a wet gas gangrene or fulminant osteomyelitis in the hindfoot, and similar conditions that preclude salvage of a functional foot. In such scenarios, patients are frequently febrile and have bacteremia.

Under these circumstances, a primary definitive amputation carries a risk for wound infection and a higher-level amputation. The initial guillotine amputation helps control the infection, eliminate the bacteremia, and provide a safer wound environment for a definitive amputation at a later date. Thus, it is preferred as a first stage to control infection, followed by a definitive below-the-knee amputation.

The release of toxins into the systemic circulation from fulminant infections in the foot and the presence of comorbidities such as diabetes mellitus can cause septic shock and compromise the ability of patients to tolerate anesthesia or prolonged surgery. In such situations, a guillotine-type amputation, which can be rapidly performed, allows removal of the diseased foot—a necessary step to eliminate systemic toxins and save the patient's life.

Although the two-stage amputation technique entails an additional operation, guillotine amputation at the ankle level is recommended as a first stage to deal with nonsalvageable infections such as wet gangrene in the midfoot or hindfoot because it allows subsequent wound closure with a reduced chance of wound infection. ^[1]  (See Outcomes.)

A guillotine-type amputation is not indicated if amputation is contemplated for conditions such as tumors or trauma or when no risk for spread of infection from a distal lesion exists.

In patients with severe peripheral vascular disease, the level of guillotine amputation may have to be higher. Wound healing for subsequent amputation is determined by the presence of adequate vascularity to heal a surgical wound.

McIntyre et al reviewed 75 below-the-knee amputations performed for nonsalvageable foot infections. ^[2]  Patients were retrospectively divided into two groups: group 1 underwent open ankle guillotine amputation followed by definitive below-the-knee amputation, and group 2 underwent primary definitive below-the-knee amputation. In group 1, 97% of patients achieved primary healing after revision, and none required amputation at a higher level. In group 2, 78% of patients achieved primary healing, but 11% required revision of the amputation to the above-the-knee level.

These data supported the following conclusion: guillotine ankle amputation followed by below-the-knee amputation for the nonsalvageable, infected lower extremity is associated with a significantly lower amputation failure rate than primary definitive amputation. ^[2]  Primary definitive amputation performed in the presence of distal extremity infection carries risk for wound infection and additional limb loss.

A similar conclusion was reached from a prospective, randomized study by Fisher et al. ^[3]  Forty-seven patients with necrotizing wet gangrene of the foot were prospectively randomized to receive either a one-stage amputation (definitive below-the-knee or above-the-knee amputation with delayed secondary skin closure in 3-5 days) or a two-stage amputation (open ankle guillotine amputation followed by definitive closed below-the-knee or above-the-knee amputation).

Twenty-four patients (11 diabetic and 13 nondiabetic) were randomized to the one-stage procedure. ^[3]  Twenty-three patients (14 diabetic and nine nondiabetic) were randomized to the two-stage procedure. Five of the 24 patients in the one-stage group (21%) had positive muscle cultures vs 10 of the 23 patients in the two-stage group (43%). Two of the 24 patients in the one-stage group (8%) had positive lymphatic cultures vs seven of the 23 patients in the two-stage group (30%). Five of the 24 patients in the one-stage group (21%) had wound complications attributable to the amputation technique vs none of 23 patients in the two-stage group.

An experimental study on guillotine amputation of the distal femur in fresh frozen self-donated cadavers was undertaken by Leech and Porter. ^[4]   A prehospital doctor conducted a surgical amputation with a Gigli saw or hacksaw for bone cuts, and firefighters carried out the procedure using the reciprocating saw and a Holmatro device. Primary outcome measures were time to full amputation and number of attempts required; secondary outcomes were observed quality of skin cut, soft-tissue cut, and computed tomography (CT) assessment of the proximal bone. Observers also noted potential risks to the rescuer or patient during the procedure.

All of the techniques completed amputation within 91 seconds. ^[4]  The reciprocating saw was the quickest (22 s), but there was significant blood spattering and continuation of the cut to the surface under the leg. The Holmatro device took less than 60 seconds. The quality of the proximal femur was acceptable with all methods, but the Holmatro device caused 5 cm more proximal soft-tissue damage.  

Emergency prehospital guillotine amputation of the distal femur can effectively be performed by using scalpel and paramedic shears with bone cuts made by a Gigli saw or fire service hacksaw. ^[4] The reciprocating saw may be used to cut bone if no other equipment is available but carries some risks. The Holmatro cutting device is a viable option for a life-threatening entrapment where only firefighters can safely access the patient, but it would not be a recommended primary technique for medical staff.

In a 2014 Cochrane review addressing types of incision for below-the-knee amputation, Tisi and Than found that in patients with wet gangrene, a two-stage procedure with a guillotine amputation at the ankle followed by a definitive long posterior flap amputation led to better primary stump healing than a one-stage procedure. ^[1]

Cheddie et al prospectively studied 100 patients (50 female, 50 male; median age, 61 years [range, 29-80]) who underwent surgery for diabetic foot sepsis over a 5-year period. ^[5]  Disease severity was classified according to the Wagner classification (Wag). Most patients had advanced disease at presentation: 71 (71%) Wag 5, 20 (20%) Wag 4, seven (7%) Wag 3, and two (2%) Wag 2. Seventy-seven patients (77%) had tibioperoneal disease, 21 (21%) had femoropopliteal disease, and two (2%) had aortoiliac disease. Surgical procedures performed were as follows:

• Above-the-knee amputation (n = 35; 35%)
• Below-the-knee amputation (n = 46; 46%)
• Transmetatarsal amputation (n = 8; 8%)
• Toe ectomy (n = 8; 8%)
• Debridement (n = 3; 3%) 

Outcome measures in this study included reamputation rate, in-hospital mortality, and length of hospital stay. ^[5] For above-the-knee amputation, the reamputation rate was 4.3%, and all of the stumps healed completely. The overall in-hospital mortality was 7%, and the median length of hospital stay was 7.8 ± 3.83 days. The authors concluded that a definitive one-stage primary amputation was a safe and effective procedure for diabetic foot sepsis, with the distinct advantages of a short hospital stay, a low reamputation rate, and a low in-hospital mortality. They suggested that guillotine amputation should be reserved for physiologically unstable patients.

Tsvetkov et al estimated the effectiveness (evaluated in terms of perioperative mortality, frequency of early complications, and ultimate level of limb loss) of a two-phase method of urgent lower-limb amputation among critically ill patients at high risk for complications. ^[6] The study retrospectively matched two groups of patients with acute lower-limb gangrene.

In the control group (n = 240), 25.8% of the patients died without surgery as a consequence of the severity of their condition and ineffective preoperative treatment; the remainder underwent one-phase high-level amputation after 48-72 hours of preoperative intensive care. ^[6]  In the experimental group (n = 153) 34.6% of the patients underwent guillotine amputation at the lower part of the tibia, 32.0% underwent knee disarticulation, and 33.3% underwent open thigh amputation, depending on the level of irreversible soft-tissue necrosis. Reamputation with stump shaping was performed later, when health status had improved.

The authors' assessment of treatment outcomes showed that the two-phase amputation in critically ill patients (1) decreased mortality from 48.7% to 37.9%, (2) reduced the risk of wound complications from 20.9% to 11.1%, and (3) improved functional results by saving the knee joint in 34.6% of cases vs 4.5% in the control group. ^[6] Accordingly, they recommended two-phase amputation for critically ill patients.