—Amputations of the toes are, by virtue of their shortness, nearly always disarticulations. The basal row of phalanges should be preserved when possible, and even here the covering of the stump should be as far as possible fashioned from the sole.
The big toe may be removed by either internal or oval plantar flaps, which should be long enough to cover the metatarsal head, otherwise the latter must be decapitated. These same principles also apply to the little toe. When all or most of the toes have to be severed it may as well be done by a single dorsal incision, as seen in [Fig. 692], which will permit either their disarticulation or their removal along with that of the ends of the metatarsals. These methods are shown in [Figs. 692] and [693].
Amputation of a toe with its metatarsal is best effected by a racket incision. This may extend up to the posterior tarsal joint. Some have recommended to enucleate the metatarsals subperiosteally, through dorsal incisions, all the soft parts being scrupulously left behind. With the first and fifth toes the scar should be so placed as to be removed from the edge of the foot ([Fig. 693]).
Partial amputations of the foot have been suggested and devised in great numbers, and the subject has been greatly complicated by the number of methods that were taught. Modern ideas of conservative surgery have caused a complete departure from the anatomist’s standard, and it has been shown that with aseptic technique there is no advantage in disarticulating when it leaves irregular lines. As Matas says: “As Agnew taught long ago in this country, and others elsewhere, the skeleton of the foot must be considered a surgical unity, to be treated by the knife and saw just as the femur and humerus would be, at the exact point which will yield the longest and most useful stump to the patient. What is essential in every case is the application of the principle of plantar flaps—preservation and scar protection.”
Concerning the utility of many of these methods and the usefulness of the resulting stumps we may learn more from the makers of artificial limbs than from almost any other source. Thus, Truax, for instance, who has had large experience as a mechanic, has given this advice, as quoted by Matas: “Avoid amputation within three inches of the ankle-joint; do not amputate between the metatarsal bones and the junction of the lower and middle thirds of the tibia. At other points save all you can, and you will in every case have done the best for your patient.” Should one be rationally governed by this advice a large number of amputation methods which cumber most text-books would be discarded.
Fig. 692
1, simultaneous disarticulation of all the toes; 2, amputation of the toes in their continuity. (Mignon.)
Fig. 693
