A Guide To Disarticulation ‘Guillotine’ Amputation Techniques

Author(s): 
Michael Donnenwerth, DPM, Sara Borkosky, DPM, and Thomas S. Roukis DPM, PhD, FACFAS

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 )

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