The Challenge of the Complete Transmetatarsal Amputation
Kelly Kempe, MD, Naema Zarish, MD, Muzamil Aziz, MD, Kate Savoie, MD, Jen Gordon, MD, Shaun Stickley, MD, Prateek Gupta, MD, Michael Rohrer, MD.
University of Tennessee, Memphis, TN, USA.
Title: The Challenge of the Complete Transmetatarsal Amputation
OBJECTIVES – A complete forefoot amputation is a challenging wound to heal. Contemporary reviews of this problem are few. This report studies a 10-year single-center experience and describes the surgical interventions and outcomes observed.
METHODS – Consecutive patients undergoing total transmetatarsal amputations (TMA) over 10 years were identified and analyzed. Demographic, comorbidities, surgical history, indications, postoperative wound complications, length of stay, and mortality data were abstracted from the electronic medical record. Results were evaluated using descriptive statistics and multivariable modeling. Survival rates and limb salvage rates were calculated using the Kaplan-Meier product-limit method.
RESULTS – TMA was performed in 131 patients. The mean age was 58.4±11.9 years; 40% of the patients were female, and 79% were African American. Seventy-four percent of the patients had diabetes, 49% had a history of peripheral arterial disease, and 33% had end-stage-renal-disease. Forty-nine percent denied any history of smoking. Fifty-eight patients (44%)had prior toe amputations before their completion TMA. Ipsilateral revascularization occurred in 47 patients the same admission as their TMA, and only 12 were documented to have a palpable pedal pulse following revascularization. The most common reason for TMA was dry gangrene (44%), followed by a soft tissue infection (34%), foot ulcer (24%), and a non-healing prior toe amputation (22%). Major amputation occurred in 27% after TMA, with a median (IQR) time to amputation of 37 (18,220) days. Forty-five (34%) patients required another surgery to their TMA site due to a complication, with 2 patients requiring up to 6 revisions. Of those 45 patients with complications after TMA, 28% limbs were subsequently salvaged. The most common reason (65%) for a forefoot site complication and a major amputation (75%) was ischemia. On multivariable analysis, limb loss was associated with concomitant soft tissue infection. Thirty-day mortality was 5%. Limb salvage was 78%, 75%, and 74% at 1, 3, and 5 years. Survival was 88%, 86%, and 82% at 1, 3, and 5 years.
CONCLUSIONS – A transmetatarsal amputation is difficult to heal, but it is a viable option for limb salvage. Poor prognostic indicators include a soft tissue infection. Although there is a mandate to reduce readmission and wound complication rates, the complete forefoot amputation should not be abandoned.
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