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Temporary Amputations and Permanent Amputations
Whatever the level of mutilation and finger concerned, carrying out a digital amputation is a significant surgical procedure with functional consequences. We speak of “temporary” amputation when a subsequent reconstruction is planned. This is most often a microsurgical reconstruction by toe transfer. In these circumstances the surgical principles governing fashioning the stump are different from those observed when the digital amputation is permanent. It is therefore crucial to understand the surgical strategy as a whole.
Permanent Amputations
General Rules
As for all surgical procedures, a digital amputation should be performed whenever possible in a single stage. It is important to fashion a satisfactory stump.
Skin Cover
A functional stump must have a mechanically adapted skin cover. Excessive soft tissue leading to a floppy digital stump must be avoided. This is unattractive and is furthermore not functional because of excess soft tissue mobility. At the other end of the spectrum, inadequately covered stumps with thin and adherent skin are often painful during grip.
Painful Stump
The existence of pain in a digital stump very often leads to its gradual exclusion. Obtaining a painless stump requires specific treatment of the digital nerves. Proximal resection of the palmar digital nerves alone, however, is an insufficient guarantee if the skin and bone are not addressed with proper surgical techniques.
Sensibility
A functional digital stump must have adequate sensation, which excludes a priori certain skin coverage solutions such as remote flaps, which at best only give a protective sensibility in the long term. Obtaining a sensitive stump is the result of a careful choice regarding closure and skin cover technique. Indirectly the sensibility obtained in the stump depends on the level of bone shortening. Depending on the clinical scenario, length should be preserved, even using a sensitive flap for coverage of the stump. On the contrary, some situations require shortening so as to allow closure by the simple apposition of two skin flaps, dorsal and palmar.
Mobility
The mobility of a digital stump depends partly on the integrity of the joints proximal to the stump and partly on the existence of motor tendons. Mobility is also linked to the level of bone shortening. When only a short segment from the base of a phalanx persists, even if the tendon insertions are intact, the mobility obtained will have little clinical utility, given the shortness of the lever arm.
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