Elsevier

Annals of Vascular Surgery

Volume 19, Issue 6, November 2005, Pages 769-773
Annals of Vascular Surgery

Healing of Transmetatarsal Amputation in the Diabetic Patient: Is Angiography Predictive?

https://doi.org/10.1007/s10016-005-7969-zGet rights and content

Transmetatarsal amputation (TMA) is a durable reconstruction in the diabetic patient with limited forefoot gangrene. However, predicting TMA healing remains difficult. Our goals were to (1) determine the success rate of TMA and (2) identify factors predictive of TMA healing, in particular arterial foot anatomy. A retrospective review of all diabetic patients undergoing TMA was done. Blood supply to the foot was classified as mostly anterior (anterior tibial and/or dorsalis pedis artery), mostly posterior (posterior tibial or plantar arteries), or equally distributed (both systems patent or peroneal runoff). Foot vessels were assigned runoff scores from 0 to 3 according to Society for Vascular Surgery/International Society for Cardiovascular Surgery (SVS/ISCVS) criteria. Forty-four TMAs in 29 men and 12 women were reviewed. Revascularization was done in 35 cases. In nine cases (20%), no bypass was deemed necessary (n = 7) or feasible (n = 2). Blood flow to the foot was deemed mostly anterior in 16 cases, mostly posterior in 17 cases, and equally distributed in 11. The TMA was left open in 19 cases and closed with staples or sutures in the rest. Limb salvage was achieved in 30 cases (68%) at a median follow-up of 48 weeks. Three of the four patients on dialysis required leg amputation (75%) vs. 11 of the 40 (27%) nondialysis patients (p = 0.05). When the TMA was left open, leg amputation was more likely (58%) than when closed primarily (12%) (p = 0.01). No angiographic factors were predictive of limb salvage. The need for revascularization was not associated with limb loss, although both patients with no feasible bypass option required below-knee amputation. TMA healing can be expected in a majority of diabetic patients after adequate revascularization but cannot be predicted by angiographic findings. Efforts should be made to achieve primary wound closure.

Section snippets

INTRODUCTION

Transmetatarsal amputation (TMA) is a durable reconstruction in the diabetic patient with forefoot tissue loss.1 However, failure to heal will still occur in a number of cases and may be related to wound factors, neuropathy, or insufficient vascular supply. A number of noninvasive vascular laboratory criteria have been correlated with the likelihood of healing of forefoot amputations.2, 3 However, no study has evaluated the relationship, if any, between foot arterial anatomy and the likelihood

METHODS

Diabetic patients undergoing TMA at our medical center over a 5-year period were identified from a query of our surgical registry. From this group, we identified a subset of patients who had also undergone lower extremity arteriography within 3 months of the TMA, either before or after. This subset of patients constitutes our study group.

The records, including hospitalization records, operative notes, clinic visits, and vascular laboratory studies, were reviewed. We recorded demographic

PATIENT POPULATION AND RESULTS

Forty-one patients were identified who underwent 44 TMAs (three had bilateral procedures). There were 29 men and 12 women, with a mean age of 59 ± 11 years. Thirty-two patients were Hispanic, seven were Caucasian, and five were African American.

Cardiovascular risk factors included hypertension in 76%, hyperlipidemia in 51%, cardiac disease in 51%, prior stroke in 7%, a history of prior smoking in 56%, and active smoking in 21%. Only four patients (10%) were on hemodialysis for chronic renal

DISCUSSION

Forefoot amputation in the form of TMA along with revascularization as needed allowed limb salvage in nearly two-thirds of diabetic patients. TMA thus appears to be a worthwhile intervention in diabetic patients. Revisions of the TMA were, however, frequently required and often still resulted in ultimate limb salvage.

Patients should not be denied the option of TMA on the basis of the arteriographic appearance of the foot since no correlation could be found between the angiographic foot anatomy

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    We also never consider data to be definitive, but do think that these results might be worthy of attention and future investigation. First, these results appear to mirror the contemporary literature in terms of the primary healing rate of the TMA (1-21). We observed a primary healing rate of 53.4% at 90 postoperative days.

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  • Transmetatarsal Amputation Outcomes When Utilized to Address Foot Gangrene and Infection: A Retrospective Chart Review

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    Existing studies comparing TMA healing rates and PAD have had mixed results. Some studies have demonstrated an increased failure rate of healing a TMA with a history of PAD (11,14), while others have not demonstrated such an association (17,18,24,26,27,32). In our study we did not find PAD to significantly affect the postoperative healing of a TMA.

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Presented at the Fifteenth Annual Winter Meeting of the Peripheral Vascular Surgery Society, Steamboat Springs, CO, January 28–30, 2005.

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