OT notes · General Surgery

Toe, ray and trans-metatarsal amputation

Usual anaesthesia
Local (digital) block or ankle block for toes; ankle block, spinal or general for ray and transmetatarsal amputation
Position
Supine, foot and leg to the knee prepared
Setting
urgent

Operative note template for toe, ray and transmetatarsal amputation, with a filled example for an open ray amputation of the second toe for wet gangrene in a diabetic foot.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • wound not healing because of poor blood supply
  • infection spreading or persisting, needing further debridement
  • gangrene of the next toe if its artery is damaged
  • need for a higher amputation later (transmetatarsal, below-knee)
  • wound left open to heal slowly, or closed later, or skin graft
  • change in foot shape and pressure points, needing special footwear
  • deep vein thrombosis while not walking

Pre-operative details for this operation

  1. IndicationDry gangreneWet gangreneOsteomyelitisNon-healing ulcerTraumawhich toes, how far proximal
  2. Perfusion assessmentpulses, ankle-brachial index, Doppler, TcPO2; revascularisation needed first or not
  3. SepsisNo systemic sepsisSeptic foot: urgent source control
  4. ImagingX-ray foot: bone involvement, gas
  5. Diabetes controlblood sugar, HbA1c, insulin plan
  6. Antibiotics and tetanusantibiotic being given (drug, since when), tetanus prophylaxis if indicated
  7. Level planned and consent for higher leveltoe / ray / partial or full TMA; consent covers going higher if needed

Anaesthesia and position

  1. AnaesthesiaDigital (web space) blockAnkle blockSpinalGeneralfor local: 1% lignocaine without adrenaline, volume
  2. PositionSupinefoot to knee painted and draped
  3. TourniquetNot usedUsed: site, pressure, time

Operative findings

  1. Extent of gangrene or infectiontoes involved, spread along tendon sheaths or plantar space, pus, gas
  2. Bonesoft or destroyed, level of healthy bone
  3. Bleeding from skin edgesGoodPoor (ischaemic)
  4. Plantar flap (TMA)length available, viable or not
  5. Adjacent toescolour, digital arteries preserved

Procedure (steps)

  1. LevelToe at proximal phalanxToe at MTP joint with metatarsal headRay (toe with part of metatarsal)Partial transmetatarsalFull transmetatarsal
  2. IncisionElliptical (2nd to 4th toe)Racquet (1st, 2nd or 5th toe, ray)Dorsal at mid-metatarsal level with long plantar flap (TMA)
  3. Soft tissue divisiondown to bone; digital arteries ligated (suture); digital artery to next toe spared
  4. Tendonsextensor and flexor tendons pulled down and divided as proximal as possible
  5. Periosteumelevated only at the level of division, not beyond
  6. Bone divisionBone cutterPower sawMetatarsal head removed with rongeurlevel (e.g. metatarsal midshaft), ends smoothed with rongeur
  7. Plantar tissues divided (TMA)plantar metatarsal arteries ligated
  8. Debridement of infected tissuetendon sheaths, plantar space opened and cleared if pus tracks
  9. Irrigation and haemostasissaline volume
  10. Wound managementClosed primarilyLeft open and packedPartly closedreason (dry gangrene / clean wound vs infection or wet gangrene)

Closure, drains and dressing

  1. Deep layer (if closed)interrupted absorbable, flap tailored to close without tension
  2. Skin (if closed)Interrupted vertical mattress nylonInterrupted monofilamentsize; not tied tight
  3. Open woundpacked with saline-soaked gauze
  4. DrainNoneUnder flap
  5. Dressingbulky protective dressing; no tape on ischaemic skin

Specimens and implants

  1. Amputated partSent for HPE (proximal bone margin marked)Handed for disposal as biomedical wasteHanded to relatives on request (documented)
  2. Deep tissue or bone for cultureSentNot sent

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Foot elevationkeep foot elevated
  2. Weight bearingno weight on the foot for 10 to 14 days after TMA; write the plan for toe or ray
  3. Woundfirst dressing day; open wounds: dressing frequency
  4. Antibioticsdrug, dose, duration; change as per culture
  5. Blood sugarfrequency and insulin scale
  6. DVT prophylaxisuntil mobile
  7. Cause of gangrenevascular assessment or revascularisation referral if not done
  8. Further plansecond look, delayed closure or skin graft; footwear review with prosthetist after healing

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. G.N., 58 years, with type 2 diabetes, wet gangrene of the right second toe for 5 days with pus tracking to the second metatarsal head, palpable dorsalis pedis and posterior tibial pulses, and no systemic sepsis.

Case details

Date: 28/09/2026. Urgent open ray amputation right second toe. Emergency OT.

In OT 10:10. Spinal given 10:20. Incision 10:40. Procedure completed 11:20.

Surgeon: Dr A. (MS 2nd-year resident), under supervision of Dr B. (MS 3rd-year resident). Consultant Dr C. informed and agreed plan.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Wet gangrene right second toe, black and foul-smelling, with pus and swelling over the dorsum at the second MTP joint. Other toes pink.

Right DP and PT pulses palpable. ABI right 0.94. Revascularisation not needed.

X-ray right foot: destruction of second proximal phalanx base and second metatarsal head, no gas in tissues.

RBS 246 mg/dl, on insulin infusion as per physician. HbA1c 9.8%. Creatinine 1.2 mg/dl.

IV antibiotic started on admission (as per chart), dose given at 09:30. Tetanus toxoid given on admission.

Consent: general, procedure-specific (ray amputation, wound left open, may need higher amputation) and anaesthesia consent taken in Kannada from patient, son present.

WHO checklist sign in and time out done. Right foot marked.

Anaesthesia and position

Spinal anaesthesia. No tourniquet used.

Supine. Right foot and leg to knee painted with povidone-iodine and draped.

Findings

Gangrene of whole second toe. Pus around second MTP joint tracking 2 cm proximally along the extensor tendon. No plantar space abscess.

Second metatarsal head soft and destroyed. Mid-shaft of second metatarsal hard and bleeding.

Skin edges bleeding well. Third toe and great toe pink, digital arteries to them preserved.

Procedure

Racquet incision around the base of the right second toe, extended over the dorsum of the second metatarsal.

Soft tissues divided down to bone. Digital arteries of the second toe ligated. Digital vessels to adjacent toes spared.

Extensor and flexor tendons of the second toe pulled down and divided as far proximally as possible. Infected extensor tendon sheath laid open and debrided.

Periosteum elevated only at the level of division. Second metatarsal divided at mid-shaft with bone cutter. End smoothed with rongeur.

Toe with distal half of second metatarsal removed.

Wound irrigated with 1 litre normal saline. Haemostasis secured.

Closure

Wound left open because of wet gangrene and pus. Packed loosely with saline-soaked gauze.

Bulky protective dressing. No tape on the skin of the foot.

Specimens and implants

Proximal piece of second metatarsal (resection margin) sent for culture and HPE for osteomyelitis at margin.

Rest of amputated toe handed over for disposal as yellow category human anatomical waste. Relatives informed and did not request the part.

No implant.

End of procedure

Estimated blood loss 50 ml.

Mop, needle and instrument counts correct, confirmed by scrub nurse.

No intra-operative complications.

Shifted to post-operative ward in stable condition. Pulse 88/min, BP 132/80 mmHg.

Post-op orders

Keep right foot elevated. No weight bearing on the right forefoot till review.

Continue IV antibiotic as per chart; review with bone culture.

Blood sugar monitoring and insulin as per physician.

DVT prophylaxis as per unit protocol until walking.

Dressing of the open wound as ordered by the consultant. Plan second look, then delayed closure or split-skin graft when the wound is clean.

Footwear review with prosthetist after healing.

Signature

Dr A., JR-2, General Surgery. Reg. no. ________. 28/09/2026, 11:35.

Must document for this operation

  • Blood supply of the foot before surgery (pulses, ABI or Doppler). A minor amputation in an ischaemic foot without revascularisation often fails, and the note must show perfusion was assessed.
  • Exact level of bone division and state of the bone at the cut end. Persistent osteomyelitis or a higher amputation later is judged against this.
  • That the digital arteries to adjacent toes were preserved. Gangrene of the next toe is a known complication, and this shows care was taken.
  • Why the wound was left open or closed. The ward team and the next surgeon plan dressings and delayed closure from this.
  • What happened to the amputated part. Relatives may ask for it, and disposal as biomedical waste must be traceable.
  • Consent for a higher level if needed. The level can change during surgery, and the consent must already cover it.

Common mistakes in these notes

  • Writing 'toe amputated' without the level (phalanx, MTP joint, metatarsal).
  • Not writing the pulses or ABI in the pre-op section.
  • Not stating whether the wound was closed or left open, and why.
  • No record of culture or histopathology (HPE) of the proximal bone.
  • No plan for weight bearing, blood sugar control and follow-up of the cause.

Indian practice and paperwork

  • Amputated body parts not sent for HPE are human anatomical waste in the yellow (a) category and go to the common biomedical waste treatment facility. Record whether relatives asked for the part. (Bio-Medical Waste Management Rules 2016, CPCB guidelines)
  • The NQAS district hospital OT checklist expects tetanus prophylaxis to be given if indicated before surgery. Record it for a gangrenous or wounded foot. (NQAS Assessor's Guidebook for District Hospitals 2020, Vol I, OT checklist ME E15.2)
  • The same checklist expects that braided biological sutures are not used in dirty wounds. (NQAS Assessor's Guidebook for District Hospitals 2020, Vol I, OT checklist ME E15.3)
  • NABH expects the operative note to be written before the patient leaves recovery, and post-op care to follow a written plan. (NABH 5th ed., COP.14(e) and (f))

Sources

  • Scott-Conner CEH, ed. Scott-Conner & Dawson: Essential Operative Techniques and Anatomy. 4th ed. Lippincott Williams & Wilkins (Wolters Kluwer); 2014, Ch 127, Transmetatarsal and Ray Amputations, pp. 685-690.
  • Bell RH Jr, Kaufman DB, eds. Northwestern Handbook of Surgical Procedures. Landes Bioscience; 2005, Ch 107, Toe Amputation (Eskandari MK); Ch 108, Transmetatarsal Amputation (Schindler N), pp. 317-320.
  • Scott-Conner CEH, ed. Scott-Conner & Dawson: Essential Operative Techniques and Anatomy. 4th ed. Lippincott Williams & Wilkins (Wolters Kluwer); 2014, Ch 128, Below-knee amputation (used only for: no tape on the skin of an ischaemic limb), pp. 694.

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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