Data from 37 patients who underwent a transmetatarsal amputation from January 1993 to April 1996 were reviewed. The mean age and diabetes duration of the subjects were 54.9 (± 13.2) years and 16.6 (± 8.9) years, respectively. The follow-up period averaged 42.1 (± 11.2) months. At the time of follow-up, 29 (78.4%) of the 37 patients still had foot salvage, 8 (21.6%) had progressed to below-the-knee amputation, and 15 (40.5%) had undergone lower-extremity revascularization. Twelve (80%) of the 15 revascularized patients preserved their transmetatarsal amputation level at a follow-up of 36.4 months. The authors concluded that at a maximum of 3 years follow-up after initial amputation, transmetatarsal amputation was a successful amputation level. (J Am Podiatr Med Assoc 91(10): 533-535, 2001)
Background: Transmetatarsal amputations are limb salvage surgical procedures that preserve limb length and functional ankle joints. Indications for transmetatarsal amputations include forefoot trauma, infection, and ischemia. Prior research demonstrates patients who undergo transmetatarsal amputations have a lower 2-year mortality rate compared to those who undergo more proximal amputations. The aim of this study was to determine whether primary closure of a transmetatarsal amputation is a superior treatment compared to secondary healing of a transmetatarsal amputation for forefoot abnormality of infection, gangrene, or chronic ulceration.
Methods: A retrospective chart review was performed on patients aged 18 years or older requiring a transmetatarsal amputation because of forefoot abnormality between September of 2011 and December of 2019. Foot and ankle surgeons performed transmetatarsal amputations. Outcome variables measured included healing time of transmetatarsal amputation site, recurrent infection, recurrent gangrene, and the need for revision surgery or higher level amputations.
Results: Of the original 112 patients, 76 met the inclusion criteria; 47 of these had primary closure of transmetatarsal amputation and 29 of these had an open transmetatarsal amputation performed. Primarily closed transmetatarsal amputations resulted in a significantly greater overall healing rate of 78.8% (37 of 47) compared to open transmetatarsal amputations, with a healing rate of 37.9% (11 of 29) (P < .01). Closed transmetatarsal amputations were statistically significantly less likely than open transmetatarsal amputations to have recurrent gangrene, require revision pedal operations, or progress to higher level amputations.
Conclusions: Our research demonstrated that primary closure of transmetatarsal amputations is a superior treatment compared with secondary healing of transmetatarsal amputations in specific cases of infection, dry gangrene, or chronically nonhealing ulcerations.
Background: The deep plantar arterial arch (DPAA) is formed by an anastomosis between the deep plantar artery and the lateral plantar artery. The potential risk of injury to the DPAA is concerning when performing transmetatarsal amputations, and care must be taken to preserve the anatomy. We sought to determine the positional anatomy of the DPAA based on anatomical landmarks that could be easily identified and palpated during transmetatarsal amputation.
Methods: In an effort to improve our understanding of the positional relationship of the DPAA to the distal metatarsal parabola, dissections were performed on 45 cadaveric feet to measure the location of the DPAA with respect to the distal metatarsal epiphyses. Images of the dissected specimens were digitally acquired and saved for measurement using in-house–written software. The mean, SD, SEM, and 95% confidence interval were calculated for all of the measurement parameters and are reported on pooled data and by sex. An independent-samples t test was used to assess for sex differences. Interrater reliability of the measurements was estimated using the intraclass correlation coefficient.
Results: The origin of the DPAA was located a mean ± SD of 35.6 ± 3.9 mm (95% confidence interval, 34.5–36.8 mm) proximal to the perpendicular line connecting the first and fifth metatarsal heads. The average interrater reliability across all of the measurements was 0.921.
Conclusions: This study provides the positional relationship of the DPAA with respect to the distal metatarsal parabola. This method is easily reproducible and may assist the foot and ankle surgeon with surgical planning and approach when performing partial pedal amputation.
The transmetatarsal amputation has been performed for over 40 years as a limb salvage procedure, in diabetic patients with nonhealing ulcerations or nonreconstructible ischemia. It is generally believed that the transmetatarsal amputation provides a better walking extremity than a more proximal amputation and is more energy efficient. A review of the literature reveals little regarding the biomechanics of the "short foot." The authors will review the functions of the myofascial structures in both the normal foot and the transmetatarsal amputation and discuss the influence of mechanics on transmetatarsal amputation lesions.
Diabetic foot infections tend to lead to amputation. Partial first-ray resections are used to help salvage the foot and maintain bipedal ambulation. Losing the first metatarsophalangeal joint has biomechanical consequences that lead to further foot deformities and result in more proximal amputations of the ipsilateral limb, such as a transmetatarsal amputation.
We reviewed 48 patients (32 male and 16 female; mean age = 62.44) who underwent 50 partial first-ray resections between April 1, 2003, and July 31, 2009. These partial first-ray resections were done at various levels of the first metatarsal. We hypothesize that partial first-ray resections that require further bone resection will lead to poor biomechanics that can result in further amputation.
We found that out of 50 partial first-ray resections, 24 cases required further surgical intervention, 12 of which were a transmetatarsal amputation (TMA) (mean time between partial first-ray resection and TMA = 282.08 days). Forty-eight percent of patients did not require further surgical intervention and were considered a success.
Partial first-ray resections are not highly successful. Our study found a higher success rate compared to a previous study done by Cohen et al in 1991. Partial first-ray amputations can be a good initial procedure to salvage the foot and prolong a patient’s bipedal ambulatory status, thereby lowering the patient’s morbidity and mortality. (J Am Podiatr Med Assoc 102(5): 412–416, 2012)
Despite advancements in the treatment of diabetic patients with “at-risk” limbs, minor and major amputations remain commonplace. The diabetic population is especially prone to surgical complications from lower extremity amputation because of comorbidities such as renal disease, hypertension, hyperlipidemia, microvascular and macrovascular disease, and peripheral neuropathy. Complication occurrence may result in increases in hospital stay duration, unplanned readmission rate, mortality rate, number of operations, and incidence of infection. Skin flap necrosis and wound healing delay secondary to inadequate perfusion of soft tissues continues to result in significant morbidity, mortality, and cost to individuals and the health-care system. Intraoperative indocyanine green fluorescent angiography for the assessment of tissue perfusion may be used to assess tissue perfusion in this patient population to minimize complications associated with amputations. This technology provides real-time functional assessment of the macrovascular and microvascular systems in addition to arterial and venous flow to and from the flap soft tissues. This case study explores the use of indocyanine green fluorescent angiography for the treatment of a diabetic patient with a large dorsal and plantar soft-tissue deficit and need for transmetatarsal amputation with nontraditional rotational flap coverage. The authors theorize that the use of indocyanine green may decrease postoperative complications and cost to the health-care system through fewer readmissions and fewer procedures.
Recurrent ulcerations may develop following transmetatarsal amputation in patients with diabetes mellitus. In many cases, these ulcerations require surgical intervention to achieve healing, especially in situations where conservative care has not been effective. These procedures range from the local resection of bone to skin grafting and flap techniques to successfully heal the wound. The ultimate goal of any surgical intervention is to prevent a more proximal amputation.
Background: Transmetatarsal amputation (TMA) is a viable option to avoid major amputation and limb loss in patients with forefoot sepsis, infection, or tissue loss. However, TMAs are associated with a significant incidence of dehiscence, readmission, and reoperation rates ranging from 26% to 63%. To encourage tissue healing, neovascularization, and durable closure, a nonwoven, resorbable, synthetic hybrid-scale fiber matrix whose architecture is similar to native human extracellular matrix was used in an augmented closure technique. We comparatively evaluated clinical outcomes and complication rates in TMA procedures with and without augmented closure.
Methods: A retrospective analysis of ten patients who underwent TMA with augmented closure using the synthetic matrix and ten patients who underwent TMA with standard primary closure was conducted.
Results: After TMA, 80% of the patients who underwent augmented closure demonstrated complete wound healing compared with 60% of the control group. Patients undergoing augmented closure demonstrated five instances of wound dehiscence and 20% limb loss compared with eight instances of wound dehiscence and 40% limb loss in the control group. After TMA and augmented closure, patients required eight interventional procedures before complete healing compared with patients undergoing standard closure, who required 13 interventional procedures before complete healing.
Conclusions: Augmented closure of surgical wounds after TMA using a synthetic hybrid-scale fiber matrix provided a unique means of reducing time to healing (18%), wound dehiscence (29%), number of procedures performed (39%), and rate of limb loss (20%). Augmented closure, therefore, offers a means of improving quality of life and reducing risk for patients undergoing TMA, and potentially reducing total cost of care.
While the transmetatarsal amputation has resulted in the salvage of numerous diabetic limbs, it remains an ablative procedure with both short- and long-term complications. The authors reviewed their experience with the panmetatarsal head resection as an alternative to the transmetatarsal amputation. A retrospective review was performed of all patients having undergone this procedure between May 1986 and November 1991. Thirty-seven procedures were performed; of these, 34 were evaluated. The average follow-up period was 20.9 months. Thirty-two feet showed primary healing while one showed delayed healing. One patient had local recurrence of the original ulceration. Primary healing was 94% while overall success was 97%. No patient required amputation of any kind. The authors conclude that the panmetatarsal head resection is a viable alternative to the transmetatarsal amputation in properly selected patients because it avoids many of the structural and biomechanical pitfalls of the transmetatarsal amputation.
The effect of diabetes on the lower extremity can be devastating. Surgical intervention on the diabetic foot must be carefully planned, and long-term results must be anticipated. The authors present a case history of a patient with multiple previous amputations of the forefoot, resulting in a severe deformity and a nonfunctional foot. Transmetatarsal amputation, if performed correctly, should provide a relatively functional extremity.