Transmetatarsal amputation: assessment of current selection criteria

doi:10.1016/j.amjsurg.2006.08.011

The American Journal of Surgery

Volume 192, Issue 5, November 2006, Pages e8-e11

Presented at the 30th Annual Surgical Symposium of the Association of VA Surgeons, Cincinnati, Ohio, May 7–9, 2006

https://doi.org/10.1016/j.amjsurg.2006.08.011 Get rights and content

Abstract

Background

Transmetatarsal amputation (TMA) is an operation designed to remove a limited area of irremediable tissue ischemia and/or infection and preserve limb function. Patients are selected for TMA based on degree of tissue loss/infection, adequacy of tissue perfusion at the transmetatarsal level, current ambulatory status, and estimation of the likelihood of postprocedure ambulation. The purpose of this study was to assess the validity of these selection criteria.

Methods

An institutional review board–approved retrospective review was conducted of all patients undergoing TMA from January 1, 1997, until January 1, 2006. Information was collected on patient demographics, medical comorbidity, and clinical and surgical variables. Outcome measures included the proportion of patients requiring amputation revision to a more proximal level and ambulatory status at last follow-up.

Results

Fifty-two TMAs were performed. In 35 procedures, the skin was left open, and in 17 TMA was closed primarily. Primary indications for the procedure were vascular insufficiency or infection in 50 of 52 patients, whereas 2 patients required amputation for malignancy. The majority (46/52, 89%) of patients were diabetic. After the index TMA, 85 additional operations were required. Only 9 patients (18%) underwent a single operation. Revision of the TMA to a more proximal level was required in 29 of 52 (56%) patients, resulting in 4 Syme, 20 transtibial, and 5 transfemoral amputations. Non–insulin-dependent diabetes was associated with an increased likelihood of revision to a more proximal amputation (odds ratio [OR] = 5.4; 95% confidence interval [CI], 1.2–24). At the time of last follow-up (median 18 months), 37 of 50 (74%) patients were ambulatory (83% for TMAs and 67% for more proximal amputations, P = 0.18). Prior vascular procedures were associated with a significantly decreased likelihood of ambulation (OR = 14; 95% CI, 1.9–103).

Conclusions

Although most patients retain the ability to ambulate after TMA, multiple operations should be anticipated in the majority of patients and revision of a TMA to a more proximal level may be required. These data suggest that current selection criteria for TMA may be inadequate.

Section snippets

Patients and Methods

An institutional review board–approved retrospective review was undertaken with the aim of identifying all patients undergoing TMA at the Dallas VA Medical Center between January 1, 1997, and December 31, 2005. Cases were identified electronically by using the current procedural terminology codes for transmetatarsal amputation (28800 and 28805). These patients were then cross-referenced with a database designed to track operative caseloads for the Department of Surgery at the University of

Results

The study population consisted of 51 men and 1 woman, with an average age of 62 years. The primary indications for TMA included localized, irremediable ischemia, and tissue loss in 5 patients; localized, irremediable ischemia tissue loss and infection in 45 patients; and malignancy in 2 patients. Noninvasive arterial testing was performed in 28 of 52 patients (54%). The remaining patients had a palpable dorsalis pedis or posterior tibial arterial pulse on physical examination.

Although most

Discussion

Patients are traditionally selected to undergo transmetatarsal amputation based on the presence of limited tissue loss or infection, sufficient perfusion to heal the amputation, and ambulatory status at the time of surgery. The 52 patients in this series represent less than 10% of lower-extremity amputations performed at this institution over the period of the study. We encountered a very high rate of failure to heal and a frequent requirement for secondary procedures. In fact, a more proximal

References (13)

B. Toursarkissian et al.
Healing of transmetatarsal amputation in the diabetic patient: is angiography predictive?
Ann Vasc Surg
(2005)
M.G. Sheahan et al.
Lower extremity minor amputations: the roles of diabetes mellitus and timing of revascularization
J Vasc Surg
(2005)
A.P. Furnary et al.
Effects of hyperglycemia and continuous intravenous insulin infusions on outcomes of cardiac surgical procedures: the Portland Diabetic Project
Endo Pract
(2004)
H. Glass et al.
Influence of transmetatarsal amputation in patients requiring lower extremity distal revascularization
Am Surg
(2004)
F.G. Quigley et al.
Transmetatarsal amputation for advanced forefoot tissue loss in elderly patients
Aust N Z J Surg
(1995)
H.M. Adera et al.
Prediction of amputation wound healing with skin perfusion pressure
J Vasc Surg
(1995)

There are more references available in the full text version of this article.

Cited by (43)

Open revascularization approach is associated with healing and ambulation after transmetatarsal amputation in patients with chronic limb threatening ischemia
2023, Journal of Vascular Surgery
Transmetatarsal amputation (TMA) allows for maintenance of ambulatory function for patients with significant forefoot tissue loss. Effective revascularization is key to optimizing limb salvage for patients with chronic limb threatening ischemia (CLTI). We hypothesized that CLTI patients requiring TMA will have better healing and functional outcomes with open bypass than with endovascular revascularization.
Consecutive TMAs performed at three affiliated centers between 2008 and 2020 were retrospectively reviewed. The baseline characteristics, including WIfI (wound, ischemia, foot infection) stage, noninvasive vascular studies, healing, and ambulatory outcomes, were collected. Catheter-based angiographic images were evaluated using the GLASS (global limb anatomic staging system). The primary outcomes were TMA healing and community ambulation. The secondary outcomes were TMA that had healed at study end, any ambulatory function postoperatively, major amputation, and mortality. Descriptive statistics and univariate, multivariable, and Kaplan-Meier analyses were performed.
A total of 346 TMAs had been performed in 318 patients, 209 of whom had had peripheral artery disease (PAD). The median follow-up was 2.5 years. Patients with PAD had had significantly lower rates of healing compared with those without PAD (64% vs 77%; P = .007). Revascularization was performed in 185 limbs, with 102 treated endovascularly and 83 with open surgery. The patients who had undergone endovascular surgery were significantly less likely to have had the TMA healed at any point (55% vs 76%; P = .003) and less likely to have remained healed at study end (49% vs 66%; P = .02). Patients with GLASS stage 3 anatomy were significantly more likely to have healed after open surgery (75% vs 45%; P = .003). Long-term ambulation data were available for 72% of the revascularized patients. Endovascular surgery was associated with a lower likelihood of community ambulation after TMA (34% vs 57%; P = .002). On multivariable analysis, open surgery was significantly associated with TMA healing (odds ratio, 2.8; P = .007) and ambulation (odds ratio, 2.9; P = .001).
For patients with CLTI and significant tissue loss requiring TMA, an initial open approach to revascularization was associated with improved healing and higher rates of ambulation compared with endovascular interventions. The metabolic requirement for healing of a TMA in patients with CLTI might be better met by open revascularization.
Predictive Factors and Amputation Level for Reamputation in Patients With Diabetic Foot: A Retrospective Case-Control Study
2022, Journal of Foot and Ankle Surgery
Citation Excerpt :
There are studies showing risk of wound healing and reamputation in distal level amputations (16). Antony et al found reamputation was performed at the proximal level in 29 (56%) of 52 patients undergoing TMM amputation during their 18-month follow-up (9). Izumi et al showed that ipsilateral reamputation rates were observed as 1-, 3-, and 5-year rates: 22.8%, 39.6%, and 52.3%, respectively.
The aim of this study was to assess the rate and level of reamputation in patients who had a previous amputation from diabetic foot. We retrospectively analyzed patients who underwent amputation and reamputation due to diabetic foot in our clinic between 2011 and 2019. Fifty-nine were evaluated as the healed group after the first amputation and 55 were evaluated as the reamputation group. Given 55 patients who needed reamputation: there were 13 finger or ray, 23 transmetatarsal or syme, 18 transtibial, and 1 transfemoral in the first operation. We found the reamputation rate was 65.4% in distal amputations. When serum parameters were examined before the first amputation in each group, there was no statistically significant difference in white blood cells, neutrophils, lymphocytes, platelets, sedimentation, C-reactive protein, total protein, hematocrit, urea, creatinine, and HgA1c values. There was, however, a significant difference between groups in albumin levels. When comorbidities were assessed for smoking, hypertension, duration of diabetes, and number of debridements after the first surgery, a significant difference between groups was found. When peripheral artery disease and chronic renal failure were examined, no significant difference was observed. In our study, it was observed that the rate of reamputation was higher in distal level amputations for diabetic foot patients. Accordingly, albumin values, smoking, hypertension, duration of diabetes, number of debridements after surgery, were seen as risk factors for reamputation patients.
The Development and Usability of the AMPREDICT Decision Support Tool: A Mixed Methods Study
2021, European Journal of Vascular and Endovascular Surgery
Amputation level decision making in patients with chronic limb threatening ischaemia is challenging. Currently, evidence relies on published average population risks rather than individual patient risks. The result is significant variation in the distribution of amputation levels across health systems, geographical regions, and time. Clinical decision support has been shown to enhance decision making, especially complex decision making. The goal of this study was to translate the previously validated AMPREDICT prediction models by developing and testing the usability of the AMPREDICT Decision Support Tool (DST), a novel, web based, clinical DST that calculates individual one year post-operative risk of death, re-amputation, and probability of achieving independent mobility by amputation level.
A mixed methods approach was used. Previously validated prediction models were translated into a web based DST with additional content and format developed by an expert panel. Tool usability was assessed using the Post-Study System Usability Questionnaire (PSSUQ; a 16 item scale with scores ranging from 1 to 7, where lower scores indicate greater usability) by 10 clinician end users from diverse specialties, sex, geography, and clinical experience. Think aloud, semi-structured, qualitative interviews evaluated the AMPREDICT DST’s look and feel, user friendliness, readability, functionality, and potential implementation challenges.
The PSSUQ overall and subscale scores were favourable, with a mean overall total score of 1.57 (standard deviation [SD] 0.69) and a range from 1.00 to 3.21. The potential clinical utility of the DST included (1) assistance in counselling patients on amputation level decisions, (2) setting outcome expectations, and (3) use as a tool in the academic environment to facilitate understanding of factors that contribute to various outcome risks.
After extensive iterative development and testing, the AMPREDICT DST was found to demonstrate strong usability characteristics and clinical relevance. Further evaluation will benefit from integration into an electronic health record with assessment of its impact on physician and patient shared amputation level decision making.
Transmetatarsal Amputation Outcomes When Utilized to Address Foot Gangrene and Infection: A Retrospective Chart Review
2021, Journal of Foot and Ankle Surgery
Citation Excerpt :
Although there are several studies in the foot and ankle literature that demonstrate a correlation between abnormally elevated hemoglobin A1c and postoperative complications (47-49), the literature in regards to TMA healing has been mixed. Some studies have demonstrated a correlation between poor glycemic control and postoperative TMA healing complications (12,25,26,31,32) with patients with noninsulin-dependent diabetes being at a 5.4 times greater likelihood of requiring a more proximal amputation (25). While other studies, similar to ours, have not found a correlation between diabetes and postoperative TMA healing complications (11,14,17,18).
A transmetatarsal amputation (TMA) is a widely utilized procedure to address foot gangrene and infection. Although a common procedure, so too are the associated complications. The purpose of this review was to evaluate TMA healing and to explore if there were associated variables correlating with healed vs. failed to heal TMA sites. To do so, the Medical Department Orthopaedics Division Electronic Database, West Virginia University, College of Medicine was retrospectively searched to identify all cases of TMAs (CPT code 28805) during the period of January 2011 through June 2019, and those variables that might impact TMA healing. Then both univariate and multivariable logistic regression analyses were performed to investigate the associations between these variables and TMA healing, and sensitivity analyses were also conducted to determine if the results resisted the influence of one unmeasured confounder. There were 39 patients (41 procedures) who would undergo a TMA. The mean average patient age was 53 (range 29-73) years old. The median postoperative follow-up period was 617 (range 199-3632) days. TMA mortality data revealed 0 deaths at 30 days, 2 (5.1%) at 1 year, 8 (20.5%) at 5 years. In our study, 29 (70.7%) of the TMAs would achieve primary healing at a median of 31 (range 16-253) days. When comparing the TMA healed group to the failed to heal group the following independent variables were considered: diabetes mellitus, HgA1c >8%, neuropathy, peripheral arterial disease, chronic kidney disease, active smoking status, previous surgery, and a clean margin metatarsal bone pathology specimen positive for osteomyelitis. Of the aforementioned, only neuropathy (odds ratio [OR] = 0.056, 95% confidence interval [CI] = 0-0.501, p = .0062) and positive bone margin (OR = 0.144, 95% CI = 0.022-0.835, p = .0385) were found to be significant in univariate logistic regression analysis. In multivariable logistic regression analyses where the potential confounders age, gender, and body mass index were accounted for, of the 8 independent variables of interest, only neuropathy (OR = 0.037, 95% CI = 0-0.497, p = .0036) remained significantly associated with the healing status. Neuropathy was present in 17 (58.6%) of the healed TMAs and in 12 (100%) of the failed to heal TMAs. However, the positive bone margin failed to reach statistical significance (OR = 0.079, 95% CI = 0-1.39, p = .1331). Results from another multivariable logistic regression model where a quadratic term for age was added revealed that positive bone specimen correlated with the TMA healing status with significance (OR = 0.051, 95% CI = 0.001- 0.560, p = .0404). A positive clean margin bone specimen was found in 3 (10.3%) of the healed TMAs and in 4 (44.4%) of the failed to heal TMAs. The sensitivity analysis where current ulceration was used as an unmeasured confounder indicated that the results regarding the association between neuropathy or positive bone margin and TMA healing, though inconclusive, resisted the influence of this unmeasured confounder. Hopefully these findings will be a beneficial addition to the current TMA literature and as such, further assist with informed surgical decision making.
A meta-analysis of mortality after minor amputation among patients with diabetes and/or peripheral vascular disease
2020, Journal of Vascular Surgery
Citation Excerpt :
The reasons for exclusion are shown in the search flowchart of the PRISMA flow diagram (Fig 1). A total of 28 studies (including 31 substudies) with 17,325 subjects were included.16-43 Of the included studies and substudies, 24 had reported the age of their sample, with a pooled mean age of 66.6 ± 4.3 years.
Foot complications in patients with diabetes or peripheral artery disease (PAD) are serious events in the life of these patients that often lead to amputations and mortality. No evidence synthesis has been reported on the mortality rates after minor lower extremity amputation; thus, a quantitative evidence synthesis was needed.
A systematic literature search was performed to identify studies that had reported the survival or mortality rates after a minor LEA. The studies were required to include one or more of the following primary outcomes: mortality rate at 30 days, 1 year, 3 years, 5 years, 6 to 7 years, or 8 to 9 years. The secondary outcomes were the mortality rates according to the anatomic location of the amputation in the foot and the independent risk factors for mortality.
A total of 28 studies with 17,325 subjects fulfilled the inclusion criteria. The meta-analytical results of the mortality rates were as follows: 3.5% at 1 month, 20% at 1 year, 28% at 3 years, 44.1% at 5 years, 51.3% at 6 to 7 years, and 58.5% at 8 to 9 years. From these studies of diabetic patients, age was the most consistent independent risk factor, followed by chronic kidney disease, PAD, and coronary artery disease. One study of patients with PAD had reported diabetes as an independent risk factor for mortality. The subgroup analysis of the four studies reporting the outcomes of patients with PAD showed greater 3- and 5-year mortality rates compared with the overall and “diabetic” results.
Mortality after minor amputation for patients with diabetes and/or PAD was found to be very high. Compared with the reported cancer data, survival was worse than that for many cancers. Just as in the case of major amputations, minor amputations should be considered a pivotal event in the life of these patients.
Risks and Risk Factors for Ipsilateral Re-Amputation in the First Year Following First Major Unilateral Dysvascular Amputation
2020, European Journal of Vascular and Endovascular Surgery
Citation Excerpt :
Their inclusion is important because it is an amputation level that is being performed increasingly to attempt limb salvage and is associated with high re-amputation rates.11–13 The identification of patients with a high risk of healing failure has been advocated to improve amputation level selection.13–15 In a recent systematic review, renal failure, limb ischaemia, and HbA1c were associated with an increased risk of healing failure after TM amputation, although ABI was not.13
To identify timing, incidence, and risk factors for ipsilateral re-amputation within 12 months of first dysvascular amputation and to determine specific subgroups of patients at each amputation level that are at increased risk.
A retrospective cohort study evaluating 7187 patients with first unilateral transmetatarsal (TM), transtibial (TT), or transfemoral (TF) amputation secondary to diabetes and/or peripheral artery disease (PAD) were identified in the VA Surgical Quality Improvement Program database between 2004 and 2014. Re-amputation was defined as any subsequent ipsilateral soft tissue/bony revision or amputation to a higher level. Twenty-three potential pre-operative risk factors (and nine potential interactions) were identified. A backward stepwise Cox regression was used to identify risk factors. Incidence rates and hazard ratios (HR) with 95% confidence intervals (CI) were computed.
The median time to highest level of re-amputation in the first year was 33 (interquartile range, 13–73) days. Risk of requiring at least one re-amputation was 41% (TM), 25% (TT), and 9% (TF). Risk factors associated with requiring re-amputation included chronic obstructive pulmonary disease, elevated white blood cell count, abnormal ankle brachial index (ABI), history of revascularisation, and alcohol misuse. TM patients who had diabetes only (HR 1.9; 95% CI 1.4–2.5), diabetes with an abnormal ankle brachial index (ABI) score (HR 2.4; 95% CI 1.8–3.2), and kidney failure (HR 1.7; 95% CI 1.3–2.1) were at the greatest risk of re-amputation. TT amputees who were smokers were also at an increased risk (HR 1.4; 95% CI 1.2–1.6).
This research identified important risk factors for failure of primary healing and need for re-amputation at the TM and TT level. If considering a TM amputation, caution should be exercised in patients with diabetes, in particular those with an abnormal ABI and/or renal failure. At the TT level, caution should be exercised in those who smoke.

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Poster presentationTransmetatarsal amputation: assessment of current selection criteria

Abstract

Background

Methods

Results

Conclusions

Section snippets

Patients and Methods

Results

Discussion

Ann Vasc Surg

J Vasc Surg

Endo Pract

Influence of transmetatarsal amputation in patients requiring lower extremity distal revascularization

Am Surg

Transmetatarsal amputation for advanced forefoot tissue loss in elderly patients

Aust N Z J Surg

Prediction of amputation wound healing with skin perfusion pressure

J Vasc Surg

Poster presentation
Transmetatarsal amputation: assessment of current selection criteria