Michael edwards 06:37, 22 November 2008 (EST)

TOE AMPUTATION

A PANTOGEN OPERATION SCRIPT

MICHAEL EDWARDS

NO INFORMATION IN THIS SCRIPT SHOULD BE USED WITHOUT THE APPROVAL OF A FULLY TRAINED PRACTISING SURGEON

THIS SCRIPT COVERS:

AMPUTATION OF BIG TOE

AMPUTATION OF TOES 2-5

MULTIPLE AMPUTATIONS

AMPUTATION OF PHALANGES

AMPUTATION INCLUDING METATARSALS

REDO AMPUTATION

FOREFOOT AMPUTATION

LAY OUT OF OPERATION SECTIONS AND STEPS

The operation is divided into SECTIONS.

The SECTIONS are displayed in sequence in the following paragraphs.

Each SECTION is divided into an unlimited number of very small STEPS.

Each STEP contains an unlimited amount of supporting information (PANTINOS)

INDICATIONS

ATHEROMATOUS ISCHAEMIA

DIABETIC GANGRENE

TRAUMA

OVER-RIDING TOE

AN ALTERNATIVE TO A BELOW KNEE AMPUTATION WHERE THERE IS IMPROVING VASCULARITY OF THE TOES

e.g. Previously healthy tissue after trauma.

Following successful sympathectomy.

Following successful vascular surgery.

From natural improvement.

CLEAR DEMARCATION BETWEEN VIABLE AND NONVIABLE TISSUE

Demarcation should be no more proximal than the mid-proximal phalanx.

For more proximal demarcation:

Consider a mid-tarsal, or even a below knee amputation for peripheral vascular :::disease.

CONTRA-INDICATIONS

ABSOLUTE CONTA-INDICATIONS

Progessive ischaemia.

Uncertain demarcation lines.

Soft tissue infection in the forefoot.

Osteomyelitis in the metatarsal.

Septic arthritis in the metatarso-phalangeal joints.

Iliac arterial block.

RELATIVE CONTRAINDICATIONS

A static degree of ischaemia.

Ischaemia in the forefoot.

Heel ulcer.

SECTION 1.00 PRELIMINARIES AND WHO SAFE SURGERY CHECKLISTS SIGN IN AND TIME OUT

STEP 1.01 CHECK YOU HAVE THE CORRECT PATIENT

STEP 1.02 CHECK YOU HAVE THE CORRECT SIDE.

STEP 1.03 CHECK YOU HAVE THE CORRECT LIMB

STEP 1.04 CHECK YOU HAVE THE CORRECT DIGIT(S)

STEP 1.05 CHECK YOU HAVE CONSENT FOR A MORE EXTENSIVE :AMPUTATION IF NEEDED

STEP 1.06 CHECK AN APPROPRIATE ANTIBIOTIC IS BEING GIVEN

In the absence of a culture sensistivity, give Amoxycillin 250mg. and Flucloxacillin ::250mg. orally or intravenously 6 hourly.

STEP 1.07 CHECK THE OTHER LIMB IS PROTECTED

Protect it from pressure or damage during the operation by means of soft padding, ::particularly under the heel.

STEP 1.08 DO NOT USE A TOURNIQUET

This may damage ischaemic tissue.

STEP 1.09 CHECK THERE IS NO OTHER PROCEDURE TO DO

STEP 1.10 CHECK THERE IS A DIATHERMY PAD

WHO SAFE SURGERY CHECKLISTS SIGN IN AND TIME OUT

SECTION 2.00 ANAESTHESIA

GENERAL ANAESTHESIA

Epidural and spinal anaesthetics are suitable alternatives.

SECTION 3.00 POSITION

Supine.

Have access from groin to toes.

SECTION 4.00 STANCE

Stand on the side of the amputation.

Have your one assistant opposite.

SECTION 5.00 REMOVE DRESSINGS

STEP 5.01 HAVE ALL DRESSINGS REMOVED

STEP 5.02 HAVE THE LEG HELD UP AT 45 DEGREES

Have an unscrubbed assistant holding the calf.

STEP 5.03 CULTURE SWAB THE TOE(S)

STEP 5.04 CLEAN THE SKIN

Clean the skin from the toes to the midcalf.

Use 2 swabs on sticks with eg 0.5% Chlorhexidine in 70% Propanol and one to dry off.

SECTION 6.00 TOWELLING UP

STEP 6.01 PLACE A LARGE SHEET ON THE OPERATING TABLE UP TO THE KNEE

STEP 6.02 WRAP THE LIMB ABOVE THE ANKLE IN A DRESSING TOWEL

STEP 6.03 HAVE THE FOOT LOWERED ONTO THE OPERATING TABLE

STEP 6.04 FASTEN THE DRESSING TOWEL ROUND THE CALF

Use a towel clip.

STEP 6.05 PLACE AN UPPER SHEET DOWN TO THE ANKLE

SECTION 7.00 SKIN INCISION

STEP 7.01 INCISE THE SKIN

Use a scalpel with a no. 10 Swann-Morton blade.

STEP 7.02 INCISE AROUND THE PLANTAR ASPECT OF THE TOE

STEP 7.03 EXTEND THE SKIN ONTO THE DORSUM OF THE FOREFOOT

This makes a tennis racquet shaped incision with a 2cm. "handle" on the dorsum of the ::forefoot in line with the metatarsal.

For amputation of the big toe:

Include the skin over the head of the first metatarsal.

This will allow access for removal of the distal part of the metatarsal bone.

For amputation of adjacent toes:

Make the "handle" of the racquet in line with the centre of the wound.

Be very conservative in trauma cases.

Be much more radical in peripheral vascular disease.

Beginners nearly always do not incise widely enough in peripheral vascular disease.

SECTION 8.00 DEEPENING THE INCISION

STEP 8.01 DEEPEN THE INCISION DOWN TO THE METATARSAL BONE

STEP 8.02 DISSECT OUT THE METATARSAL BONE

Use dissecting scissors.

Carefully free the distal half of the metatarsal(s) from the skin, subcutaneous fat muscle ::and tendons.

If you meet pus:

Take a swab.

Clean out the cavity.

Expect delayed wound healing.

SECTION 9.00 CUTTING THE BONE

STEP 9.01 RETRACT THE PROXIMAL SKIN FLAPS

Use a Langenbeck retractor.

STEP 9.02 CUT THE METATARSAL BONE

Use bone cutters.

Cut the bone transversely, half way down its length.

Check you do not damage the soft tissues.

STEP 9.03 TRIM THE BONE ENDS

Use bone nibblers to give a transverse amputation free from sharp edges.

If you encounter necrotic bone:

Remove this tissue completely.

Necrotic bone is soft, crumbly, usually associated with pus, and may be separate from :::the rest of the metatarsal.

STEP 9.04 CHECK HAEMOSTASIS

Use diathermy.

STEP 9.05 CHECK THE SWAB, NEEDLE, AND INSTRUMENT COUNTS

SECTION 10.00 WOUND CLOSURE

STEP 10.01 CLOSE THE WOUND

Only close the wound if:

The tissues are healthy,

The skin flaps are loose enough to virtually fall together.

There is no infection.

Use eg interrupted 3/0 Vicryl (Ethicon W9890).

IN ALL OTHER CASES:

Just cover the wound with a Paraffin gauze dressing.

SECTION 11.00 DRESSINGS

STEP 11.01 COVER THE AMPUTATION SITE

Use 10 dressing gauzes.

STEP 11.02 APPLY A CREPE BANDAGE

Wind a 10cm. crepe bandage over the dressing gauzes, around the toes, foot and

ankle.

Use half full stretch tension.

Fasten the bandage with 2 pieces of 2.5cm zinc oxide plaster.

STEP 11.03 CHECK THERE IS NO OTHER PROCEDURE TO DO

STEP 11.04 PROTECT THE HEELS

Use sponge pads under the heels.

SECTION 12.00 FINAL TOUCHES AND WHO SAFE SURGERY CHECKLIST SIGN OUT

STEP 12.01 PRESCRIBE ANTI-BIOTICS IF NOT GIVEN EARLIER

According to swab sensitivity,

Or Amoxycillin and Flucloxacillin 250 mgms. q.d.s. for 5 days ( except for the presence ::of Penicillin hypersensitivity.)

STEP 12.01 PRESCRIBE CALCIUM HEPARIN

Give 5000 units subcutaneously b.d. until the patient leaves hospital.

STEP 12.02 WRITE LEGIBLE OPERATION DETAILS

STEP 12.03 FILL IN THE SURGICAL AUDIT FORM

STEP 12.04 FILL IN THE MICROBIOLOGY FORM

STEP 12.05 WRITE A LETTER TO THE GENERAL PRACTITIONER AND REFERRING :PHYSICIAN

END OF OPERATION

WHO SAFE SURGERY CHECKLIST SIGN OUT

SECTION 13.00 EQUIPMENT AND MATERIALS LIST

BASIC PACK ORTHO KNEE INSTRUMENTS

2 SPONGE HOLDERS

CHARNLEYS P.E.

2 NEEDLE HOLDER

SBONE FILE

5 LANES TISSUE FORCEPS

BONE CUTTER

20 CURVED JOLLS FORCEPS

BONE NIBBLER ASS TOWEL CLIPS

BLAKES RETRACTOR

ASS SCISSORS

1 NONTOOTHED DISSECTING FORCEPS

2X NO 4 KNIFE HANDLES

2 LARGE LANGENBECKS

PREPARATION HIBITANE WET X2, DRY X1, ETHER METH X1

SUTURES NO MATERIAL TIES

FASCIA

FAT

SKIN 1X W9890 3/0 VICRYL

DRAIN

BLADES 2X 22

DIATHERMY MONOPOLAR, FLEX, HOLDER, MEDIUM FORCEPS

DRAINS 0

TABLE FITTINGS

WOUND ANTIBIOTIC 0

WOUND INFILTRATION 0

SPRAYS 0

CATHETERS 0

DRESSINGS

PARAFFIN GAUZE

DRESSING GAUZE

10 CM CREPE BANDAGE

2.5 CM ZINC OXIDE PLASTER

ADDITIONAL ITEMS 0

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