Toe and Partial Foot Amputations
Robert G. Atnip, MD
N ormal ambulation is a complex process made possible
by the architecture of the foot and by the machinery of
the neuromuscular axis. Amputation of any portion of the
foot will alter the process of ambulation in degrees ranging
from trivial to prohibitive, depending not simply on the
amount of tissue removed, but also on the existing health and
functional status of the patient. For any given patient, ambu-
lation will be impaired in direct proportion to the amount of
tissue removed. Further consideration of this concept will be
included in the discussion of each amputation level in the
ensuing paragraphs.
The most commonly employed levels of amputation are
the phalangeal and transmetatarsal, each of which can be
single or multiple, and are sometimes performed in combi-
nation. Less common are amputations performed through
the midfoot (Chopart and Lisfranc), and hindfoot (Syme)
(Fig. 1).
Anatomy of the Foot and Toes
The complexity of the foot is illustrated by an accounting of
its components: 26 bones, 33 joints, and over 100 muscles,
ligaments, and tendons, in addition to fatty tissue, vessels,
and nerves, and its investing envelope of skin. These struc-
tures are somewhat artificially divided into three zones: the
forefoot, including the phalanges, sesamoids, and metatarsals
of the five digits; the midfoot, composed of the five tarsal
bones, and the hindfoot, made up of the talus and calcaneus.
The range of motion of the foot includes plantar flexion,
powered by the posterior compartment muscles (tibialis pos-
terior and flexor digitorum), and innervated by the posterior
tibial nerve. Extension of the foot, also called dorsiflexion, is
enabled by the anterior compartment muscles (tibialis ante-
rior and extensor digitorum), innervated by the anterior tibial
(deep peroneal) nerve. Eversion is performed by the pero-
neus muscles and is rather limited in range. Inversion derives
from the posterior muscles and is equally limited in range.
The intrinsic muscles of the foot (lumbricals and interossei)
complement the extrinsic forces to maintain balance, allow
for finer movements of the toes, and contribute signficantly
Penn State Hershey Medical Center, College of Medicine of the Pennsylvania
State University, 500 University Drive, Hershey, PA.
Address reprint requests to Dr. Robert G. Atnip, Professor of Surgery and
Radiology, Chief of Vascular Surgery, Penn State Hershey Medical Cen-
ter, College of Medicine of the Pennsylvania State University, 500 Uni-
versity Drive, Hershey, PA 17033-2390. E-mail: ratnip@psu.edu
1524-153X/05/$-see front matter © 2005 Elsevier Inc. All rights reserved.
doi:10.1053/j.optechgensurg.2005.07.002
to preserving the normal architecture. Multiple ligaments in-
cluding the large plantar fascia are essential to create and
maintain joint stability.
Sensory innervation is supplied by five nerves: the super-
ficial peroneal for the dorsal surface; the deep peroneal for a
very small area of the first web space; the sural for the poste-
rior and lateral areas; the saphenous for the medial aspect;
and the posterior tibial for the plantar surface. Of these
nerves, only the posterior tibial is crucial for normal function,
as it provides protective sensation on the weight-bearing sur-
face.
Arterial supply derives from the posterior tibial artery, the
dorsalis pedis (a continuation of the anterior tibial), and the
peroneal artery. The latter vessel ends in smaller branches at
the ankle, but the two tibial vessels extend into the foot to
form the plantar arches and directly nourish the forefoot and
toes. Each toe has medial and lateral digital arteries and
nerves.
Phalangeal Amputation
The hallux has two phalanges, and the other four digits have
three, with the distal phalanx being the smallest. Beyond this
simple anatomic difference, the hallux overshadows the
other digits in functional importance by virtue of its roles in
balance of the forefoot and in push-off during ambulation.
Although the second toe can adapt to some extent in the
absence of the great toe, patients who have lost the hallux
invariably notice a substantial difference in the mechanics of
walking, especially after transmetatarsal amputation. Ampu-
tations of the great toe should be performed for only the
strictest and most carefully considered indications.
Although amputation of only the distal part of a toe is
technically possible, there is little functional advantage to
having half or two-thirds of a toe, even the great toe. Certainly
in any situation where perfusion is abnormal, digital ampu-
tations are best performed through the base of the proximal
phalanx, leaving a relatively short stump with a better likeli-
hood of healing.
Digital amputations are typically performed with a “fish-
mouth” technique, which is preferred to a circular incision in
all cases intended for primary closure. Since the vessels
course along the medial and lateral aspects of the toe, it is
sensible to orient the fishmouth in the anterior-posterior
(dorsal-plantar) direction, so that the bases of the flaps are
medial and lateral, including the digital vessels. Nonetheless,
many surgeons obtain equally good results from the use of a
67
68 R.G. Atnip

The ideal flaps will be just long enough to coapt without

tension, but “too long” is always preferable to “too short.”
When faced with inadequate soft tissue for closure, the sur-
geon can use standard plastic techniques to mobilize the flaps
further, or can attempt to shorten the bone, even to the point
of excising the entire base of the phalanx. The options in that
case are to convert to a transmetatarsal amputation (see next
section), or to leave the metatarsal head intact. In the latter
case, it is imperative to remove the articular cartilage to avoid
necrosis and infection of this nonvascular tissue layer.
As described in a previous section, closure of the skin can
be accomplished with the suture method and material of
choice, provided that the technique is as gentle and atrau-
matic as possible. A minimal number of sutures. combined
with interspersed thin adhesive strips, provide a secure clo-
sure with minimal tissue injury.

Transmetatarsal
Amputation (TMA)
This procedure consists of amputation of one or more toes
along with a portion of the corresponding metatarsal bone(s).
The success of the procedure depends heavily on the health
and integrity of the plantar skin and soft tissues that will
provide coverage of the bone stump and ultimately form the
weight bearing surface. Transmetatarsal amputation is a very
useful and effective method for treating ischemic necrosis of
the forefoot, and often represents the patient’s last hope for
salvage of a functional foot. In cases where the plantar tissues

Figure 1 The skeleton of the foot, showing the level of bony transec-
tion for each of the four standard toe or partial foot amputations.
Creation of the soft-tissue flaps for each of these procedures is de-
scribed in more detail in the text.

medial-lateral fishmouth with anterior and posterior flaps. In

either case, the incisions are arc shaped and symmetric, each
encompassing a hemi-circumference of the toe. It is often
necessary for the apex of the flap to extend rather close to the
margin of necrosis, but the surgeon must visually verify that
the skin margins of the flap are viable and not grossly in-
fected. If the surgeon has any doubt regarding the skin mar-
gins, the wound might be better left open temporarily.
The soft tissue of the toes is sparse, consisting of skin,
minimal subcutaneous fat with nerves and vessels, investing
fascia, and tendons within their sheaths. Flaps must therefore
be incised perpendicular to the skin, full thickness down to
the bone, preserving all soft tissue with the flap. The flaps
should initially be generously long (as the distal pathology
permits), with the intent of shortening them to optimal
length for a tension-free closure. After stripping of the peri-
osteum, the bone should be amputated through the mid-
shaft, and then shortened and smoothed with a rongeur
down to the base, taking care not to violate the metatarso- Figure 2 A simple amputation through the proximal phalanx of the
phalangeal joint. The large flexor and extensor tendons left great toe. Symmetric medial and lateral flaps have been created,
should be then be distracted, amputated sharply, and al- based on the digital arteries. The stump of the phalanx is visible in
lowed to retract into the deeper soft tissues. Any final de- the base of the wound, along with the cut ends of the extensor and
bridement of the flaps can then be performed (Fig. 2). flexor tendons.
Toe and partial foot amputations 69

of the forefoot are extensively compromised, however, TMA

is unlikely to be a realistic option.
It is important to note that TMA includes resection of the
metatarsal head. Although sometimes tempting, amputation
of a toe through the metatarso-phalangeal (MTP) joint should
be avoided for several reasons. Leaving the metatarsal head
does not improve function, and instead creates a potential
pressure point that may predispose to recurrent ulceration
and infection. The bulk of the metatarsal head can make skin
closure more difficult. Since articular cartilage depends on
synovial fluid for its nutrient supply, the cartilage may die
once the joint has been disrupted. Removing the cartilage but
leaving the bony head offers no advantage over amputation of
the entire distal metatarsal.
Transmetatarsal amputation is indicated primarily in two
situations: necrosis or ulceration of the toe(s) at or proximal
to the level of the MTP joint; and/or plantar pressure ulcer-
ation over the metatarsal heads. The extent of the amputation
is dictated by the extent of necrosis, and can encompass a
single toe, two or three toes, or the entire forefoot. These
variations will be considered separately in the following para-
graphs.

Single Outer-Toe TMA

The toe and its metatarsal are sometimes called a “ray,” and
the corresponding surgery can be called a “ray” amputation.
The most commonly performed single ray amputations are
those of the first or fifth toes. Each is performed by the use of
a “racket-handle” incision consisting of an elliptical cut
around the base of the affected toe, and a straight incision
starting at the proximal end of the ellipse and continuing
along the outer edge of the metatarsal shaft (Fig. 3). The exact
contour of the incision must often be modified by the pattern
of ulceration or necrosis of the toe, but must be designed to
preserve as much plantar skin and soft tissue as possible. It is
often convenient to use the elliptical incision to disarticulate
the toe at the MTP joint, and thus remove this ulcerated or
dead tissue from the surgical field before proceeding with the
deeper dissection. This technique has the added advantage
that the metatarsal is easier to visualize and isolate after the
toe itself has been removed (Fig. 4).
After disarticulation of the MTP joint, the joint capsule
must be sharply and completely separated from the metatar-
sal head. Great care must be taken in avoiding entry into the
MTP joint of the adjacent ray, and in avoiding injury to the
plantar soft tissues abutting the shaft of the metatarsal. (In
these tissues are located the arterial supply to the plantar
flap.) Once the head is free, one then proceeds with stripping
of the periosteum of the metatarsal shaft to the desired level
using a small elevator. The shaft is then divided with a bone
cutter and recessed with a rongeur so that the stump is bev-
eled with the shorter edge on the plantar surface (to avoid a
pressure point) (Fig. 5).
The next step is to excise the remnants of the joint capsule,
which in the case of the first toe, will include the sesamoid
bone. These structures are virtually avascular and heal
poorly. The dissection is best done with a very sharp #15
scalpel blade, taking only the ligamentous and bony compo-
nents, and sparing the plantar fascia and other soft tissues.
Once the tissue resection has been completed, one must
Figure 3 An example of the “racket-handle” type of incision used for
transmetatarsal amputation of the great toe. The racket joins the
handle over the medial aspect of the metatarso-phalangeal joint, and
the handle extends along the metatarsal shaft. This incision can be
modified for combined amputations of the first and second toes, and
can also be used for amputation of the fifth toe, or of the fourth and
fifth toes together.
then assess the closure potential of the dorsal and plantar
flaps. If at all possible, any redundancy should be trimmed
from the dorsal flap rather than the plantar, unless the plantar
tissue appears to be of poor quality. In cases where the flaps
will not approximate without tension, the surgeon has the
choices of resecting more bone, debulking the flaps, leaving
part of the wound open, or amputating the adjacent ray to
mobilize more soft tissue. When all is satisfactory, closure is
then performed as described in the preceding section.
Single Inner-Toe TMA
Transmetatarsal amputation of an inner toe (toes 2, 3, or 4)
can be a useful procedure, but requires modifications in tech-
nique. Because of the constraints imposed by the adjacent
rays, it is more difficult to perform isolated TMA of an inner
toe, and more difficult to obtain good closure. If the plantar
tissues are relatively normal, the amputation can be done
using the racket-handle technique, with the handle extend-
ing from the dorsal end of the ellipse along the dorsal surface
of the metatarsal shaft. Added difficulties occur when the
plantar skin is ulcerated or ischemic, in which case, it is
impossible to avoid an incision on the plantar weight-bearing
surface. In either case, the operation proceeds best by disar-
ticulating and removing the toe at the MTP joint, freeing the
70
head from the joint capsule (while not entering the adjacent
joints), stripping and resecting the desired length of shaft,
and excising the remnants of joint capsule before closing. The
essentially fixed position of the adjacent metatarsal rays can
make it rather difficult to close an inner-toe TMA without
skin tension. The foot can be wrapped to compress the meta-
tarsals and reduce tension on the suture line, but only if
precautions are taken to avoid pressure ulceration from the
bandage itself.
Figure 5 Transmetatarsal amputation
of the great toe. The metatarsal shaft
has been cut on a posterior bevel, and
the plantar flap has been trimmed of
excess soft tissue. The flexor tendon
has been cut shorter than the bone.
The joint capsule of the adjacent sec-
ond MTP joint is intact, and has not
been entered or disrupted.
R.G. Atnip
Figure 4 Transmetatarsal amputation
of the great toe. The specimen has
been removed after disarticulation of
the metatarso-phalangeal joint. The
sesamoid bone has been carefully ex-
cised from the plantar flap. The
transected flexor hallucis longus ten-
don can be seen posterior to the shaft
of the metatarsal. The plantar flap is
redundant, and will need to be
sculpted and trimmed before closure.
Multiple TMA
Although in theory any combination of toes could be ampu-
tated at the TMA level, such a decision should take into
account the relative importance of the various toes in the
stability of the foot and the mechanics of walking. Significant
stability and function are lost with amputation of the great
toe, especially at the TMA level, and the loss is even greater if
the second toe is also taken. To perform TMA of the first three
toes would likely be a disservice to the patient, leaving him/
Toe and partial foot amputations 71

her with a narrow, tapered, and dysfunctional forefoot. Sim-

ilarly, the more toes removed from the lateral aspect of the
foot, the greater the asymmetry and imbalance of forces on
the remaining rays.
The technique for multiple TMA is a simple modification
of that for first or fifth ray amputation. An ellipitical incision
is created to encompass the base of the affected toes, modified
as needed to incorporate any areas of dorsal or plantar necro-
sis. The racket handle then extends along the outer aspect of
the metatarsal shaft. Flaps are created in identical fashion to
standard TMA. The MTP joints are disarticulated, the meta-
tarsal shafts amputated, recessed, and beveled appropriately.
The flaps are then sculpted and closed without tension.
Although preservation of the medial toes is more advanta-
geous than saving the lateral toes, it is questionable whether
TMA of more than two adjacent rays should ever be per-
formed. In patients with diabetic or other polyneuropathies,
amputations that create gross asymmetry of the forefoot are
associated with a notoriously high incidence of subsequent
breakdown and re-amputation. As a general rule, balance,
function, and stump integrity will be better with a complete
(full-foot) transmetatarsal amputation.

Full-Foot TMA
Amputation of the entire forefoot at the transmetatarsal level
is one of the most useful procedures in the surgical armamen-
tarium. When properly performed, full-foot TMA results in a
symmetric stump with favorable weight distribution. Al-
though there is no question that patients with TMA must
learn to adapt their balance, gait, and stride after loss of the
forefoot, most patients will be able to walk, either indepen-
dently or with simple supportive devices. Foot orthoses or
custom shoes can be useful to facilitate walking, but prosthe-
ses are not necessary.
If the plantar tissues are intact, the plantar incision for
TMA crosses the foot as close to the base of the toes as pos-
sible. The dorsal incision is made across the mid- to distal
level of the metatarsal shafts, as dictated by the pattern of
forefoot necrosis (Fig. 6). The dorsal and plantar incisions are
then connected by axial incisions made along the shafts of the
first and fifth metatarsals. The result will be a plantar flap of
variable length. In developing the plantar flap, the incision
should be carried down to the MTP joints, which should all
then be disarticulated. This allows the surgeon to find the
proper plane along the plantar surface of the metatarsal head
and shaft. From the plantar approach, the metatarsal shafts
angle toward the dorsum of the foot as they traverse proxi-
mally, and it is imperative that the surgeon adhere closely to
the shafts to preserve the muscles and vessels of the plantar
flap.
The dorsal incision is carried directly down through the
soft tissues, extensor tendons, and dorsal vessels to the ante-
rior surface of the metatarsal shafts. At the desired level, these
shafts are stripped of periosteum and divided with bone cut-
ter or rongeur. Working simultaneously from the plantar
surface, the interosseus muscles are divided along with any
remaining ligaments and tendons, and the specimen re-
moved. The metatarsal stumps should be recessed and bev-
eled, shorter on the plantar aspect.
Remaining on the plantar flap at this point will be the
Figure 6 Flaps outlined for a “full foot” transmetatarsal amputation.
The plantar flap is long, and the plantar incision extends along the
base of the toes. The dorsal incision crosses transversely over the
mid- to distal level of the metatarsal shafts. Either the dorsal or
plantar incisions may need to be modified if there is ulceration or
necrosis of the forefoot.
sesamoid bones and portions of the joint capsules, which
should be carefully excised, leaving adjacent muscle and ves-
sels intact. All potentially viable skin and soft tissue of both
dorsal and plantar flaps should be spared until the final stage
of the procedure. Excess tissue can be removed and flaps
trimmed during closure, once it is known how the flaps can
best be re-approximated.
In the presence of ulceration or necrosis on the plantar
surface, the placement of the plantar incision and the creation
of the plantar flap will need to be individualized. In the
common case of a neuropathic ulcer penetrating to the meta-
tarsal head, the ulcer can be excised in elliptical or V-shaped
fashion, which in essence will create two plantar flaps and
hence require a final T-shaped suture line. If the plantar
necrosis is more medial or lateral than central, the remaining
plantar tissue can often be rotated to achieve final closure. In
such situations, some of the metatarsal shafts may need to be
amputated shorter than others to enable closure of the flaps
without tension. It is in these cases that the imagination and
reconstructive skill of the surgeon become especially impor-
tant.
Like most amputations below the ankle, a full-foot TMA
lends itself to only one layer of closure, the skin. In essence,
the dorsal surface consists of skin, virtually no subcutaneous
fat, and a very thin layer of fascia. If the plantar flap is too
long, it should be shortened to eliminate redundancy and
dead space (and thereby minimize the chance of hematoma).
The optimal length is that which brings the plantar tissues up
72
to abut and securely cover the bony stumps with minimal
dead space, while allowing the plantar and dorsal skin to be
sutured without tension (Fig. 7).
Given that the success and functionality of forefoot am-
putation are much superior to that of mid- or hindfoot
amputations, there can be a role for a certain surgical
“license” in performing modified TMA for patients with
extensive forefoot necrosis. One option is to amputate the
metatarsal shafts very short, provided that the surgeon is
aware of the dangers inherent in violating the tarso-meta-
tarsal joints. Removal of the first and/or fifth metatarsal
bases will result in loss of part of the insertion of the
tibialis posterior and peroneus tendons, respectively. The
ensuing imbalance of forces on the TMA stump leads to
deformity, pressure ulceration, and impaired walking.
Wholesale entry into the tarso-metatarsal joints is tanta-
mount to performing a Lisfranc amputation, which is dis-
cussed in the following section.
If the bone and deeper tissues are viable but local coverage
is inadequate, vacuum-assisted closure and/or skin grafting
may allow an “open” TMA to eventually heal. In rare cases,
the surgeon may wish to consider a free tissue transfer to
salvage the foot, but an almost ideal set of conditions must
pertain to justify such a complex undertaking. The indica-
tions, techniques, risks, and outcomes of free-tissue transfer
are beyond the scope of this monograph.
Midfoot Amputations
(Lisfranc and Chopart)
These two surgical procedures were introduced by French
surgeons in the 19th century, and they were supposedly first
R.G. Atnip
Figure 7 Closure of the transmetatar-
sal amputation with simple inter-
rupted sutures. The metatarsal shafts
have been cut with a posterior bevel,
essentially flush with the dorsal inci-
sion. The plantar flap has been
sculpted to approximate the dorsal
tissue without tension or redundancy.
employed in America by battlefield surgeons in the Civil
War. They hold out the prospect of saving part of the foot in
patients who fail or are not eligible for TMA, but they are
seldom used in modern amputation surgery. The chief dis-
advantage of the Lisfranc and Chopart procedures is that they
disrupt the tendinous attachments of the midfoot and predis-
pose to stump deformities associated with dysfunctional am-
bulation. The loss of foot length and loss of tendon insertions
leaves the plantar flexors almost unopposed, resulting in an
equinus deformity, with a consequent shift of weight bearing
from the calcaneus onto the stump itself. Although technical
modifications have been introduced that partly compensate
for this imbalance of forces, midfoot amputation has still not
gained wide acceptance as an alternative to below-knee am-
putation. Braces and prostheses are usually required for
walking, and there is a relatively high incidence of conversion
to BKA.
The Lisfranc amputation is essentially a disarticulation of
the tarso-metatarsal joints, using a plantar flap for coverage
with a technique virtually identical to transmetatarsal ampu-
tation. The important technical point is to remove as much
articular cartilage as possible from the cuneiform and cuboid
surfaces to circumvent cartilaginous necrosis. Various ten-
don transfers, reattachments, and tendo-Achilles lengthening
(TAL) have been proposed to prevent equinus deformity, but
results are often suboptimal.
The Chopart amputation shortens the foot even further
by removing the entire mid- and forefoot through the
talo-navicular and calcaneo-cuboid joints. Once again, a
plantar flap is used for coverage, but problems with stump
deformity tend to be even more common than with the
Lisfranc.
Toe and partial foot amputations
Conclusions
Locomotion is a fundamental human activity made possible
by the structure and function of the foot. Most humans con-
sider the potential loss of part or all of the foot as catastrophic,
and view amputation as a disfiguring and destructive proce-
dure. Yet due to either trauma or disease, as many as 150,000
patients per year are confronted with the necessity for ampu-
tation surgery, virtually always with no realistic alternative.
For these patients, properly performed amputation surgery is
a reconstructive procedure that rehabilitates and restores qual-
ity of life, albeit, a different life than the patient might desire.
Although many patients have such advanced disease that loss
of the entire foot is inevitable, for some the goal of partial foot
salvage is achievable. This chapter has described a variety of
procedures that preserve structure and function of the foot
sufficient to enable ambulation without a limb prosthesis. To
achieve the best results for each patient, the surgeon perform-
73
ing amputations must approach each procedure with the
finest exacting technique and attention to detail worthy of the
craft.
Suggested Reading
Attinger C, Cooper P, Blume P, Bulan E: The safest surgical incisions and
amputations applying the angiosome priciples and using the Doppler to
assess the arterial-arterial connections of the foot and ankle. Foot and
Ankle Clinics 6:745-799, 2001
Crinnion J, Hicks D: Transmetatarsal amputation: an 8-year experience. Ann
R Coll Surg Engl 84:291-295, 2002
Funk C, Young G: Subtotal pedal amputations. Biomechanical and intraop-
erative considerations. J Am Podiatr Med Assoc 91:6-12, 2001
Pinzur MS, Pinto MA, Schon LC, Smith DG: Controversies in amputation
surgery. Instr Course Lect 52:445-451, 2003
Rumenapf G: Borderline amputations in diabetics— open questions and
critical evaluation. Zentralblatt für Chirurgie 128:726-733, 2003
Sanders LJ: Transmetatarsal and midfoot amputations. Clin Podiatr Med
Surg 14:741-762, 1997
Smith DG: Principles of partial foot amputations in the diabetic. Instr Course
Lect 48:321-329, 1999