What are the reported outcomes of guillotine ankle amputation?

Updated: Nov 18, 2019
  • Author: Vinod K Panchbhavi, MD, FACS; Chief Editor: Erik D Schraga, MD  more...
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McIntyre et al reviewed 75 below-the-knee amputations performed for nonsalvageable foot infections. [2]  Patients were retrospectively divided into two groups: group 1 underwent open ankle guillotine amputation followed by definitive below-the-knee amputation, and group 2 underwent primary definitive below-the-knee amputation. In group 1, 97% of patients achieved primary healing after revision, and none required amputation at a higher level. In group 2, 78% of patients achieved primary healing, but 11% required revision of the amputation to the above-the-knee level.

These data supported the following conclusion: guillotine ankle amputation followed by below-the-knee amputation for the nonsalvageable, infected lower extremity is associated with a significantly lower amputation failure rate than primary definitive amputation. [2]  Primary definitive amputation performed in the presence of distal extremity infection carries risk for wound infection and additional limb loss.

A similar conclusion was reached from a prospective, randomized study by Fisher et al. [3]  Forty-seven patients with necrotizing wet gangrene of the foot were prospectively randomized to receive either a one-stage amputation (definitive below-the-knee or above-the-knee amputation with delayed secondary skin closure in 3-5 days) or a two-stage amputation (open ankle guillotine amputation followed by definitive closed below-the-knee or above-the-knee amputation).

Twenty-four patients (11 diabetic and 13 nondiabetic) were randomized to the one-stage procedure. [3]  Twenty-three patients (14 diabetic and nine nondiabetic) were randomized to the two-stage procedure. Five of the 24 patients in the one-stage group (21%) had positive muscle cultures vs 10 of the 23 patients in the two-stage group (43%). Two of the 24 patients in the one-stage group (8%) had positive lymphatic cultures vs seven of the 23 patients in the two-stage group (30%). Five of the 24 patients in the one-stage group (21%) had wound complications attributable to the amputation technique vs none of 23 patients in the two-stage group.

An experimental study on guillotine amputation of the distal femur in fresh frozen self-donated cadavers was undertaken by Leech and Porter. [4]   A prehospital doctor conducted a surgical amputation with a Gigli saw or hacksaw for bone cuts, and firefighters carried out the procedure using the reciprocating saw and a Holmatro device. Primary outcome measures were time to full amputation and number of attempts required; secondary outcomes were observed quality of skin cut, soft-tissue cut, and computed tomography (CT) assessment of the proximal bone. Observers also noted potential risks to the rescuer or patient during the procedure.

All of the techniques completed amputation within 91 seconds. [4]  The reciprocating saw was the quickest (22 s), but there was significant blood spattering and continuation of the cut to the surface under the leg. The Holmatro device took less than 60 seconds. The quality of the proximal femur was acceptable with all methods, but the Homatro device caused 5 cm more proximal soft-tissue damage.  

Emergency prehospital guillotine amputation of the distal femur can effectively be performed by using scalpel and paramedic shears with bone cuts made by a Gigli saw or fire service hacksaw. [4] The reciprocating saw may be used to cut bone if no other equipment is available but carries some risks. The Holmatro cutting device is a viable option for a life-threatening entrapment where only firefighters can safely access the patient, but it would not be a recommended primary technique for medical staff.

In a 2014 Cochrane review addressing types of incision for below-the-knee amputation, Tisi and Than found that in patients with wet gangrene, a two-stage procedure with a guillotine amputation at the ankle followed by a definitive long posterior flap amputation led to better primary stump healing than a one-stage procedure. [1]

Cheddie et al prospectively studied 100 patients (50 female, 50 male; median age, 61 years [range, 29-80]) who underwent surgery for diabetic foot sepsis over a 5-year period. [5]  Disease severity was classified according to the Wagner classification (Wag). Most patients had advanced disease at presentation: 71 (71%) Wag 5, 20 (20%) Wag 4, seven (7%) Wag 3, and two (2%) Wag 2. Seventy-seven patients (77%) had tibioperoneal disease, 21 (21%) had femoropopliteal disease, and two (2%) had aortoiliac disease. Surgical procedures performed were as follows:

  • Above-the-knee amputation (n = 35; 35%)
  • Below-the-knee amputation (n = 46; 46%)
  • Transmetatarsal amputation (n = 8; 8%)
  • Toe ectomy (n = 8; 8%)
  • Debridement (n = 3; 3%) 

Outcome measures in this study included reamputation rate, in-hospital mortality, and length of hospital stay. [5]  For above-the-knee amputation, the reamputation rate was 4.3%, and all of the stumps healed completely. The overall in-hospital mortality was 7%, and the median length of hospital stay was 7.8 ± 3.83 days. The authors concluded that a definitive one-stage primary amputation was a safe and effective procedure for diabetic foot sepsis, with the distinct advantages of a short hospital stay, a low reamputation rate, and a low in-hospital mortality. They suggested that guillotine amputation should be reserved for physiologically unstable patients.

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