Toe Amputation
[Diabetes-related foot infection / Osteomyelitis / Gangrene / Ischemic necrosis / Trauma / Other], [right / left] [great / second / third / fourth / fifth] toe
Same
[Transphalangeal amputation / Interphalangeal-joint disarticulation / Metatarsophalangeal-joint disarticulation] of the [right / left] [great / second / third / fourth / fifth] toe
[***, MD/DO]
[Resident/Fellow/PA name]
[General / Regional / Ankle block / Local with monitored anesthesia care]
The patient is a [age]-year-old [male / female] with [infection / osteomyelitis / gangrene / ischemic necrosis / traumatic injury] involving the [right / left] [great / second / third / fourth / fifth] toe. Examination and imaging demonstrated [wound, bone, and soft-tissue findings]. Perfusion assessment by [clinical examination and pedal Doppler / noninvasive vascular testing / angiography] demonstrated [findings]. Treatment options, the anticipated amputation level, risks, benefits, and alternatives were discussed. Informed consent was obtained.
The [right / left] [great / second / third / fourth / fifth] toe had [infected / gangrenous / ischemic / traumatically nonviable] tissue extending to [level]. [Purulence was present in the soft tissue or joint / No purulence was present.] The retained tissue at the selected amputation level was viable. The metatarsal head and adjacent soft tissue were [viable and preserved / involved as described].
The patient was positioned supine. After anesthesia was established, the operative extremity was prepared and draped in sterile fashion. A surgical time-out confirmed the patient, procedure, side, and toe. [A [calf / ankle] tourniquet was inflated to [pressure] mmHg for [duration] minutes / No tourniquet was used.]
A [fish-mouth / racquet] incision was designed at the planned level using the available viable soft tissue. Full-thickness flaps were elevated, and nonviable skin and subcutaneous tissue were excised. The flexor and extensor tendons were delivered distally, divided, and allowed to retract. The digital vessels were controlled. The digital nerves were placed under gentle traction and divided sharply so they retracted into viable tissue.
[The involved phalanx was divided at the planned level with a saw. / The [interphalangeal / metatarsophalangeal] joint was disarticulated under direct visualization.] Residual bone was contoured until no sharp prominence remained. Additional nonviable or infected tissue was excised to viable tissue. The retained bone, adjacent joint, and soft tissues were inspected.
The amputated toe was sent to pathology. [No additional specimens were obtained. / Deep tissue was sent for culture. / Deep tissue was sent for culture, and a separately labeled proximal bone margin was obtained with a fresh instrument for culture and histopathology.] The wound was irrigated, the tourniquet was released when used, and hemostasis was confirmed. The wound was [closed primarily without undue tension / left open for staged reassessment because ***]. A sterile dressing was applied. All counts were correct. The patient tolerated the procedure and was transferred to PACU in stable condition.
None
Amputated [right / left] [great / second / third / fourth / fifth] toe to pathology
[No additional specimens / Deep tissue to microbiology / Deep tissue to microbiology and separately labeled proximal bone margin to microbiology and pathology]
[*** mL]
None
The patient was transferred to PACU in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Diabetes-related foot infection / Osteomyelitis / Gangrene / Ischemic necrosis / Trauma / Other], [right / left] [great / second / third / fourth / fifth] toe
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: [Transphalangeal amputation / Interphalangeal-joint disarticulation / Metatarsophalangeal-joint disarticulation] of the [right / left] [great / second / third / fourth / fifth] toe
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: [General / Regional / Ankle block / Local with monitored anesthesia care]
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with [infection / osteomyelitis / gangrene / ischemic necrosis / traumatic injury] involving the [right / left] [great / second / third / fourth / fifth] toe. Examination and imaging demonstrated [wound, bone, and soft-tissue findings]. Perfusion assessment demonstrated [findings]. Treatment options, the anticipated level, risks, benefits, and alternatives were discussed, and informed consent was obtained.
FINDINGS: The [right / left] [great / second / third / fourth / fifth] toe had [infected / gangrenous / ischemic / traumatically nonviable] tissue extending to [level]. [Purulence was present / No purulence was present.] The retained tissue at the selected level was viable. The metatarsal head and adjacent tissue were [viable and preserved / involved as described].
DESCRIPTION OF PROCEDURE:
The patient was positioned supine. After anesthesia, the extremity was prepared and draped sterilely. A time-out confirmed the patient, procedure, side, and toe. [A [location] tourniquet was inflated to *** mmHg for *** minutes / No tourniquet was used.]
A [fish-mouth / racquet] incision was designed at the planned level using viable soft tissue. Full-thickness flaps were elevated, and nonviable tissue was excised. The flexor and extensor tendons were delivered distally, divided, and allowed to retract. The digital vessels were controlled. The digital nerves were divided sharply under gentle traction so they retracted into viable tissue.
[The involved phalanx was divided at the planned level with a saw. / The [interphalangeal / metatarsophalangeal] joint was disarticulated under direct visualization.] Residual bone was contoured until smooth. Additional nonviable or infected tissue was excised to viable tissue. The retained bone, adjacent joint, and soft tissues were inspected.
The amputated toe was sent to pathology. [No additional specimens were obtained. / Deep tissue was sent for culture. / Deep tissue was sent for culture, and a separately labeled proximal bone margin was obtained with a fresh instrument for culture and histopathology.] The wound was irrigated, the tourniquet was released when used, and hemostasis was confirmed. The wound was [closed primarily without undue tension / left open for staged reassessment because ***]. A sterile dressing was applied. All counts were correct. The patient tolerated the procedure and was transferred to PACU in stable condition.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: Amputated toe to pathology; [no additional specimens / deep tissue to microbiology / deep tissue to microbiology and separately labeled proximal bone margin to microbiology and pathology]
COMPLICATIONS: None
DRAINS: None
DISPOSITION: PACU in stable condition
Signed: .ME, .MYDEGREE
.TODAYVariants
Great-toe amputation with proximal-phalanx base preservation
When the pathology and available soft tissue permit, amputation through the proximal phalanx can preserve approximately 1 cm of its base together with the short-flexor and plantar attachments. Document the actual level and retained bone rather than assuming preservation was possible. Use an incision based on the viable tissue envelope, divide the phalanx at the selected level, contour the residual bone, and state whether the metatarsophalangeal joint and metatarsal head were preserved.
Metatarsophalangeal-joint disarticulation
Describe the dorsal and plantar flaps, capsular division, and protection of adjacent digital branches. The neurovascular bundles can be divided distal to the common digital bifurcation to avoid jeopardizing the neighboring toe. Document the condition of the metatarsal head and articular surface, and for a great-toe disarticulation state whether the sesamoids were preserved or removed and why.
Single-ray amputation
Document whether a first, central, or fifth ray was removed; the amount of metatarsal retained; the orientation and contour of the bone cut; the condition of adjacent tissues; and the closure strategy. For a fifth-ray resection, state whether the fifth-metatarsal base and peroneus brevis attachment were preserved or whether tendon reconstruction was performed. If a first-ray resection reaches the metatarsal base, document the relevant tendon attachments and any reconstruction. For central-ray resection, describe the remaining metatarsal alignment and whether contamination required delayed closure.
Charting Tips
- Document the side, exact toe, and exact level; distinguish a bone transection from an interphalangeal- or metatarsophalangeal-joint disarticulation.
- Describe the proximal extent of infection, necrosis, trauma, or tissue loss and the appearance of the tissue retained at the selected level.
- Record flap design and viability, whether the closure was tension-free, and why the wound was closed primarily, staged, or left open.
- Document tendon, vessel, nerve, residual-bone, metatarsal-head, and adjacent-joint management.
- When infection is present, identify deep-tissue and proximal bone-margin specimens separately by source and destination.
- Record the actual perfusion assessment and tourniquet use, including location, pressure, and duration when applicable.
Documentation & Reimbursement Considerations
- Report Toe Amputation as the primary service when it is the definitive operation performed.
- Toe removal at the metatarsophalangeal or interphalangeal joint generally carries a 0-day Medicare global period; removal of a single ray carries a 90-day global period.
- Medicare requires an anatomic toe designation. Document the exact toe and laterality so the claim can use the payer-required designation.
- Do not report hand and foot services interchangeably.
- A separately reported metatarsal-head or condylar service should reflect distinct work rather than bone removal inherent to the documented amputation level.