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From 1982 to 1991, 17 patients underwent a lower extremity arterial bypass to salvage an ischemic transmetatarsal amputation at the New England Deaconess Hospital. Eleven patients were male, and 16 had diabetes for an average of 29 years. The mean age was 71 years. Twelve patients presented with an ischemic ulcer, one had rest pain, and four underwent bypass for failure to heal a transmetatarsal amputation. Twelve patients presented with findings of secondary infection. All 17 patients underwent successful lower extremity bypass procedures to a variety of outflow vessels. Thirteen bypasses were to infrapopliteal arteries, including four to the dorsalis pedis artery. There were no perioperative deaths and all patients were discharged with patent grafts and healing limbs. Actuarial graft patency of the 14 vein grafts was 90% at 2 years. Actuarial limb salvage for the entire group was 93% at 2 years. Thirteen of the 14 patients who maintained patent grafts and healed their transmetatarsal amputations were ambulatory at their last known follow-up examination. Ischemic complications of previously created transmetatarsal amputations are uncommon. However, limb salvage attempts by lower extremity arterial bypass have a high likelihood of success. Major amputation in these patients should not be done without having first undergone a comprehensive vascular evaluation.
A talectomy was performed because of Charcot degeneration during recovery from a hallux amputation. The patient was treated conservatively but Charcot degeneration continued, resulting in ulceration and dorsomedial dislocation of the talar head. The patient was hospitalized, and the talectomy was performed. The patient returned to normal activities.
The Boyd amputation is a surgical technique used to treat osteomyelitis of the foot. This amputation is a technically more difficult procedure to perform than the Syme amputation, but it offers certain advantages. The Boyd amputation provides a more solid stump because it preserves the function of the plantar heel pad. Also, because a portion of the calcaneus is left and fused to the tibia, the weightbearing surface is more solid than in the case of a Syme amputation. The authors recommend a Boyd amputation as an alternative to a Syme or a below-the-knee amputation to treat patients with osteomyelitis of the forefoot and midfoot.
Background
We evaluated whether direct or indirect endovascular revascularization based on the angiosome model affects outcomes in type 2 diabetes and critical limb ischemia.
Methods
From 2010 to 2015, 603 patients with type 2 diabetes were admitted for critical limb ischemia and submitted to endovascular revascularization. Among these patients, 314 (52%) underwent direct and 123 (20%) indirect revascularization, depending on whether the flow to the artery directly feeding the site of ulceration, according to the angiosome model, was successfully acquired; 166 patients (28%) were judged unable to be revascularized. Outcomes were healing, major amputation, and mortality rates.
Results
An overall healing rate of 62.5% was observed: patients who did not receive percutaneous transluminal angioplasty presented a healing rate of 58.4% (P < .02 versus revascularized patients). A higher healing rate was observed in the direct versus the indirect group (82.4% versus 50.4%; P < .001). The major amputation rate was significantly higher in the indirect versus the direct group (9.2% versus 3.2%; P < .05). The overall mortality rate was 21.6%, and it was higher in the indirect versus the direct group (24% versus 14%; P < .05).
Conclusions
These data show that direct revascularization of arteries supplying the diabetic foot ulcer site by means of the angiosome model is associated with a higher healing rate and lower risk of amputation and death compared with the indirect procedure. These results support use of the angiosome model in type 2 diabetes with critical limb ischemia.
Forefoot Ulcer Recurrence Following Partial First Ray Amputation
The Role of Tendo-Achilles Lengthening
The coronavirus disease of 2019 pandemic is driving significant change in the health-care system and disrupting the best practices for diabetic limb preservation, leaving large numbers of patients without care. Patients with diabetes and foot ulcers are at increased risk for infections, hospitalization, amputations, and death. Podiatric care is associated with fewer diabetes-related amputations, emergency room visits, hospitalizations, length-of-stay, and costs. However, podiatrists must mobilize and adopt the new paradigm of shifts away from hospital care to community-based care. Implementing the proposed Pandemic Diabetic Foot Triage System, in-home visits, higher acuity office visits, telemedicine, and remote patient monitoring can help podiatrists manage patients while reducing the coronavirus disease of 2019 risk. The goal of podiatrists during the pandemic is to reduce the burden on the health-care system by keeping diabetic foot and wound patients safe, functional, and at home.
In March 1949, McKittrick described the use of the transmetatarsal amputation for the diabetic foot, along with specific indications. Infection, ischemia, and neuropathic ulcerations of the toes and forefoot were all treated with this procedure. In the past 30 years, however, advances in the management of these problems have led to a decrease in the number of transmetatarsal amputations performed at the New England Deaconess Hospital. With these advances, the current approach to the transmetatarsal amputation has changed, leading to significant modifications in the basic indications for this procedure.
Recurrent ulceration following transmetatarsal amputation commonly results from hypertrophic bone formation or equinus deformity. In the current study, 31 diabetic patients underwent 33 Achilles tendon procedures for recurrent ulcerations at the distal stump of their transmetatarsal amputation. Primary healing was achieved in 21 procedures (64%) and secondary healing in 9 procedures (27%) for an overall healing rate of 91%. Two procedures failed to resolve the original ulceration (6%). The average follow-up examination was 27 months. The authors conclude that Achilles tendon procedures are an effective means of managing ulcerations in transmetatarsal amputation feet exhibiting an equinus deformity.
The purpose of this study was to determine whether Medicare patients at risk for lower-extremity amputation due to complications from diabetes, peripheral vascular disease, and/or gangrene who receive the services classified under Level II code M0101 of the Health Care Financing Administration's Common Procedure Coding System (cutting or removal of corns, calluses, and/or trimming of nails, application of skin creams and other hygienic and preventive maintenance care) have lower rates of lower-extremity amputation than those who do not receive such services. Analysis of the data suggests that those at-risk beneficiaries who received these services were nearly four times less likely to experience lower-extremity amputation than those who did not receive such services. The study has both methodologic limitations (the study considers only one variable, receipt or nonreceipt of certain types of podiatric medical care, while other variables may affect rates of lower-extremity amputation) and technological limitations (attempts to link the 2 years of per case Medicare Part B data were unsuccessful, limiting the length of the study to 1 year). Further research on this topic is encouraged.
