A Guide To Disarticulation ‘Guillotine’ Amputation Techniques

When it comes to life-threatening infections in the lower extremity, a disarticulation or “guillotine” amputation may be a consideration. Accordingly, these authors review the literature to discuss indications, potential merits and step-by-step pearls to help facilitate optimal outcomes.

Necrotizing foot infections frequently result in the need for proximal amputation.1-5 Although preservation of limb length primarily and foot length secondarily are goals of functional limb salvage, in its purest sense, successful limb salvage involves preservation of a functional knee joint that one can fit with a prosthesis.5

   It is well known that primary amputation in close proximity to a septic field can lead to unacceptable failure rates and subsequent need for amputation through or above the knee joint, thereby leading to a nonfunctional limb. Patients who require above knee amputation (AKA) have significantly worse outcomes than those with below the knee amputation (BKA).6 In addition, patients with an AKA expend approximately twice as much energy to ambulate as those with BKA.7

   Aulivola and colleagues found that in a series of 959 consecutive major amputations in 788 patients, 30-day mortality rates are significantly worse for patients undergoing AKA versus BKA (16.5 percent and 5.7 percent, respectively).6 Survival rates at one and five years were 74.5 percent and 37.8 percent respectively for patients with BKA. This is compared with 50.6 percent and 22.5 percent survival at one and five years for patients undergoing AKA. These findings led to the conclusion that preserving the knee is not only important for the patient’s functional abilities, prosthetic fit and energy expenditure during ambulation, but to the survival of the patient beyond the perioperative period.

What The Research Says About Guillotine Amputation

The literature has postulated that a two stage approach involving primary disarticulation or “guillotine” amputation followed by a secondary definitive amputation can lead to a higher rate of successful limb salvage compared with a single stage approach.8,9

   Fitzmaurice-Kelly first advocated guillotine amputation during World War I as a life-saving measure for severe infections following contaminated war-related extremity wounds.10 Surgeons could perform guillotine amputation at any joint level or through a segment of bone adjacent to a joint. In the foot, the most common locations include: isolated or multiple metatarsophalangeal joints; the Lisfranc’s transverse tarsal joint complex; the Chopart’s midtarsal joint complex; ankle joint and/or distal tibia-fibula syndesmosis.

   Guillotine amputation at any of these levels, with appropriate decompression fasciotomy, irrigation and packing with polymethylmethacrylate antibiotic (PMMA) loaded cement beads, rapidly ablates the cause for the patient’s sepsis and affords optimization of their medical comorbidities. (Editor’s note: For a related PodiatryLIVE™ video co-authored by Dr. Roukis, see the “Creating Antibiotic Loaded Bone Cement” video at www.podiatrylive.com/creating-antibiotic-loaded-bone-cement )

   Should the patient remain critically ill, surgeons can simply irrigate the residual guillotine amputation site at bedside under clean conditions and pack the site daily with PMMA beads until definitive amputation at a functional level can occur. In the presence of life threatening foot infections, a staged approach produces the most optimal circumstance for salvage of a functional knee joint.

   Fisher and coworkers performed a randomized control study involving 47 patients, 24 in a single stage BKA and 23 in a two-stage amputation for wet gangrene of the foot.8 Twenty-one percent of the patients undergoing the single stage BKA had wound healing problems that required revision. In comparison, none of the patients who underwent a two-stage amputation required revision. Other authors have reported improved success with wound healing by utilizing the two-stage method as well as opposed to a primary BKA in the face of limb- and life-threatening infection.9,11-13

   The ability to achieve optimization of medical comorbidities, preservation of the soft tissue envelope, as well as delivery of parenteral and local antibiosis outweighs the risks associated with a second anesthesia exposure with the two staged approach.

Essential Surgical Insights

Surgeons may perform guillotine amputations at any level in the foot or ankle with the patient in a supine position. Tourniquet control is not required as the technique involves direct visualization, ligation and subsequent transection of the arterial and venous structures, thereby limiting blood loss. We employ an adhesive antimicrobial surgical incision barrier to cover all infected tissue and sharp towel clamps to the digits to maintain a “no touch” technique.

   Determine the appropriate level of disarticulation based on the most proximal extent of infection. Be sure to consider all clearly infected, nonviable and necrotic tissue. The initial incision is through the skin only. Utilize a monopolar electrocautery unit to coagulate superficial bleeders and then carry dissection through the subcutaneous layer to the deep fascia. Beneath the deep fascia, identify the named vascular structures and separate them from surrounding tissues. Ligate the structures via a vascular “stick tie” or locking stitch with non-absorbable sutures and coagulate the exposed ends of the vascular structures to limit the potential for hemorrhage during the postoperative period.

   Leave the suture ends long to identify and manipulate vessels if hemorrhage does occur. Transect neurological structures via monopolar electrocautery in order to coagulate the small vascular vessels, which course throughout the nerve and are a potential source of postoperative bleeding. Identify tendons through manipulation of the distal segment of the foot corresponding to the tendon structure and perform transection via monopolar electrocautery under tension. The dissection will now be at the level of the underlying joint to be incised for the disarticulation and one transects all ligaments via monopolar electrocautery.

   Manipulation of the foot during this process will dilate the joint(s) and grant wider exposure and access. The surgeon should work in this systematic fashion from the dorsal aspect of the foot medially to the lateral surface and finally to the plantar aspect, being meticulous in the dissection of each layer as we noted above.

   Resect any residual infected or necrotic tissue until the remaining tissues are all well perfused and healthy in appearance regardless of the amount of tissue that you must remove. Once you have disarticulated the infected portion, promptly remove the specimen from the field and send it to pathology for gross examination.

   At this point, carry out systematic irrigation with pulse lavage and obtain deep cultures. We prefer to irrigate with large volumes of antibiotic impregnated fluid with a pulse lavage system. Following this, all individuals involved in the operation change their gloves and remove any instruments they used prior to irrigation from the field.

   Following the disarticulation and systematic irrigation, a clinically apparent reduction in erythema and edema to the remaining lower extremity should be evident. If not, adequate resection has not occurred and a more detailed examination is necessary to determine if any undrained abscess or levels of necrotic tissue persist that would warrant a more proximal disarticulation.

   Surgeons should systematically irrigate the wound and then pack the wound with PMMA loaded cement beads that one fashions by hand. The surgeon would subsequently apply a bulky soft Jones-type dressing to control edema and absorb any bleeding.4,14

   The aforementioned technique should require approximately 20 minutes for a transmetatarsal-phalangeal joint disarticulation and 40 minutes for an ankle disarticulation from the initial incision to the final dressing application.

In Conclusion

When one properly performs this procedure, disarticulation amputation allows stabilization of the residual limb. It is our experience that within a few days, one can perform a definitive amputation. During the time period prior to the time of definitive amputation, one should ensure that the patient is hemodynamically stable and medically optimized as this allows for the greatest potential to heal unremarkably.

   It is important to emphasize that this approach requires a multidisciplinary team with open communication in order to achieve consistently good outcomes and functional residual limbs.

   Dr. Donnenwerth is a first resident (PGY-1) in the Podiatric Medicine and Surgery (PMS36) residency program at Gundersen Lutheran Medical Center in La Crosse, Wis.

   Dr. Borkosky is a first resident (PGY-1) in the Podiatric Medicine and Surgery (PMS36) residency program at Gundersen Lutheran Medical Center.

   Dr. Roukis is attending staff member in the Department of Orthopaedics, Podiatry and Sports Medicine at Gundersen Lutheran Medical Center. He is a Member of the Board of Directors and a Fellow of the American College of Foot and Ankle Surgeons.

References

1. Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS, Karchmer AW, LeFrock JL, Lew DP, Mader JT, Norden C, Tan JS. Diagnosis and treatment of diabetic foot infections. Plast Recon Surg. 2006; 117(7S): 212S-238S.

2. Nather A, Bee CS, Huak CY, Chew JL, Lin CB, Neo S, Sim EY. Epidemiology of diabetic foot problems and predictive factors for limb loss. J Diab Comp. 2008; 22(2):77-82.

3. Ozalay M, Ozkoc G, Akpinar S, Hersekli MA, Tandogan RN. Necrotizing soft-tissue infection of a limb: clinical presentation and factors related to mortality. Foot Ank Int. 2006; 27(8): 598-605.

4. Andersen CA, Roukis TS. The diabetic foot. Surg Clin. 2007; 87(5):1149-1177.

5. Zgonis T, Roukis TS. A systematic approach to diabetic foot infections. Adv Ther. 2005; 22(3):244-262.

6. Aulivola B, Hile CN, Hamdan AD, Sheahan MG, Veraldi, JR, Skillman JJ, Campbell DR, Scovell SD, LoGerfo FW, Pomposelli FB. Major lower extremity amputation: outcome of a modern series. Arch Surg. 2004; 139(4):395-399.

7. Huang CT, Jackson JR, Moore NB, Fine PR, Traugh GH, Saunders PT. Amputation: energy cost of ambulation. Arch Phys Med Rehab. 1979; 60(1):18-24.

8. Fisher DF, Clagett GP, Fry RE, Humble TH, Fry WJ. One-stage versus two-stage amputation for wet gangrene of the lower extremity: a randomized study. J Vasc Surg. 1988; 8(4):428-433.

9. Desai Y, Robbs JV, Keenan JP. Staged below-knee amputation for septic peripheral lesions due to ischaemia. Br J Surg. 1986; 73(5):392-394.

10. Fitzmaurice-Kelly M. The flapless amputation. Br J Surg. 1915; 3(12):676-681.

11. McIntyre KE, Bailey SA, Malone JM, Goldstone J. Guillotine amputation in the treatment of nonsalvageable lower-extremity infections. Arch Surg. 1984; 119(4):450-453.

12. Fearon J, Campbell DR, Hoar CS, Gibbons GW, Rowbotham JL, Wheelock FC. Improved results with diabetic below-knee amputations. Arch Surg. 1985; 120(7):777-780.

13. Kernek CB, Rozzi WB. Simplified two-stage below-knee amputation for unsalvageable diabetic foot infections. Clin Orthop Rel Res. 1990; 261:251-256.

14. Schade VL, Roukis TS. The role of polymethylmethacrylate antibiotic–loaded cement in addition to debridement for the treatment of soft tissue and osseous infections of the foot and ankle. J Foot Ank Surg. 2010; 49(1): 55-62.