Amputation: digit

• Amputation of non-functional or seriously diseased digit.

• Digital amputation may be required for:
  • Severely comminuted fractures Metacarpus, metatarsus and phalanges: fracture.
  • Intra-articular fractures.
  • Chronic sprains, or recurrent luxations.
  • Severe soft tissue injuries, eg degloving injuries, severed tendons.
  • Marked degenerative joint disease causing pain which is unresponsive to medical management.
  • Neoplasia Digit: neoplasia.
  • Chronic bacterial or fungal infection, eg osteomyelitis Osteomyelitis, onychomycosis Paronychia, which is unresponsive to medical management.
  • Developmental or acquired digital malformation causing pain or lameness.
  • Salvage of a weight-bearing pad or portion of the paw.

• Severed tendons: tendon repair.
• Fractures: stable internal fixation Fracture: internal fixation.
• Degloving injuries: open wound management Wound: management - overview or skin grafts Skin: free grafting.

Preparation

• 45 min.

Procedure

• 45 min.

Even where every effort is taken to achieve meticulous hemostasis, a moderate amount of hemorrhage can be expected.

Criteria for choosing test

• Orthogonal radiographs Radiography: carpus and forefoot of the affected foot should be taken to assess the degree of bony involvement and to plan the level of amputation.
• If neoplasia Digit: neoplasia suspected, perform right and left inflated thoracic radiographs Radiography: thorax to rule out meastasis. Thoroughly palpate all lymph nodes and take a fine needle aspiration (FNA ) or biopsy of enlarged nodes to aid in tumor staging. Results from a biopsy of the primary lesion will allow planning for appropriate surgical margins of excision.
• The removed portion should be sent in its entirety for histopathology. Bacterial or fungal culture should also be considered.
• Low grade persistent lameness may occur after amputation of the 3rd and/or 4th digits, which are the main weight bearing digits. Lameness may also occur if more than two digits are amputated and these considerations apply particularly to large breed dogs.

Ideal equipment

• Bone cutters, fine tooth hacksaw or oscillating saw.
• Tourniquet (some adhesive dressing, eg Vetwrap/CoFlex will be ideal).
• Fine mosquito hemostats or ideally the provision of monopolar/bipolar diathermy.

Pre-anesthetic preparation

• Fast animal for 12 hours prior to anesthesia to prevent regurgitation and subsequent reflux esophagitis or aspiration pneumonia Lung: aspiration pneumonia. Water should be freely available.
• Consider serum biochemistry and electrolytes:
  • In geriatric patients, ie over 8 years.
  • If systemic disease, eg renal or hepatic, is suspected.
  • If neoplasia is suspected or confirmed (ensure total Blood biochemistry: total calcium or ionized calcium Blood biochemistry: ionized calcium is included).
• Consider complete blood count Hematology: complete blood count (CBC) if infection is suspected.

Anesthesia

• Premedication: acepromazine Acepromazine or diazepam Diazepam /midazolam Midazolam in combination with an opioid (ideally a full µ-agonist, eg morphine Morphine or methadone Methadone) 30 mins before induction.
• Induction: Propofol, alfaxanone Alphaxalone Alphadalone, or thiopentone Thiopental.
• Local anesthesia: lidocaine Lidocaine ( without adrenaline) and bupivicaine Bupivacaine combination can be used to administer a ring block, splash block, nerve block (eg radial/medial/ulnar block , brachial plexus block) or intravenous anesthesia, ie Bier block.
• Consider lumbrosacral epidural administration of opioids Epidural analgesia technique.
• A non-steroidal anti-inflammatory drug, eg meloxicam Meloxicam or carprofen Carprofen, should be provided intraoperatively if appropriate.
• Perioperative antibiosis could be administered if necessary.

• Position the animal in lateral or ventral recumbency.
• Completely clip the affected limb distal to the mid-antebrachium or mid-tibial region, including all the toes.
• Secure a towel clamp onto a healthy nail and use a tie from the towel clamp to a hook or drip stand in order to elevate the limb from the surgical table and patient's body.
• Once the area is grossly clean, scrub the whole clipped region (including between the digits and pads) vigorously for at least 5 mins with a suitable preparation, eg chlorhexidine Chlorhexidine. A final liberal application of surgical spirit completes the preparation.

• ​Quarter drape the limb and release the aseptically prepared paw into the sterile field. Apply a tourniquet to the limb starting from the nail tips and working proximally. Cut the tourniquet distally to expose the digits  .

• General anesthesia General anesthesia: overview.

Step 1 - Incision

• Make Y-incision starting over the distal end of the affected metacarpal (metatarsal) and progressing round each side of the appropriate interphalangeal joint. The two arms of the Y incision should meet on the palmar/plantar aspect of the digit .

Step 2 - Bone exposure

• Transect the soft tissue down to expose bone using combination of blunt and sharp dissection to remove the extensor and flexor tendons, ligaments and joint capsule .
• Clamp the digital arteries and veins (on the dorsal and ventral aspect of the digits) with mosquito hemostats and use diathermy or ligate with suitable absorbable suture material, eg poliglecaprone 25.
• Once the bone has been exposed, use blunt dissection to undermine the soft tissue proximally. By pushing this soft tissue proximally when the bone is cut, this will ensure that there is plenty of soft tissue available to achieve a tension-free closure.

Step 3 - Bone incision

• Transect the phalynx with an oscillating saw, hacksaw or bone cutters .
• When the transection is performed through the metocarpophalangeal joint, the palmar sesamoid bones should also be removed.

Step 4 - Close wound

• Check for and address any further hemorrhage.
• Appose subcutaneous tissues over the end of the bone using absorbable material (eg polydiaxanone). Placement of the subcutaneous sutures should close any dead space and ensure that there is no tension in the overlying skin .
• Close the skin with simple interrupted sutures, eg nylon.

General care

• The foot should be dressed with an appropriate primary layer, eg Primapore or Melolin, and generous amounts of padding applied. Ensure that there is light padding between the toes and under any dew claws.
• Tight bandages may cause swelling or ischemic necrosis.
• The dressing should be kept clean and dry and the owner should be instructed how to examine the bandage daily ​.
• The dressing should be changed or removed after three days.
• The skin sutures should be removed after 7-10 days.

Other medication

• Non-steroidal anti-inflammatory medication should be continued for 5-7 days post-operatively.
• Post-operative antibiotic administration may or may not be necessary depending on the reason for amputation.

Special precausions

• Restrict exercise for 3 weeks until wound is completely healed.

• Wound dehiscence.
• Hemorrhage.
• Infection.
• Persistent lameness.

• Generally good.
• Guarded when neoplasia is involved.
• Always send affected digit to histolopathology and/or bacterial/fungal culture.

• Skin tension.
• Infection or poor control of hemorrhage.
• Bandage too tight.
• Development of metastases.

Refereed papers

• Recent references from PubMed and VetMedResource.

Other sources of information

• Probst C W, Millis D L (2003) Digit Amputation. In: Textbook of Small Animal Surgery, 3rd edn, pp 1987. Ed Slatter D, Saunders, Philadelphia.
• Hedlund C S (2002) Digit Amputation. In: Small Animal Surgery, 2nd edn, pp 206-207. Eds Fossum T W, Hedlund C S, Hulse D A, Johnson AL, Seim H B, Willard M D, Carroll G L, Mosby Inc, Missouri.