Original research
Mortality and Morbidity After Transmetatarsal Amputation: Retrospective Review of 101 Cases

Presented at the 63rd Annual Scientific Conference of the American College of Foot and Ankle Surgeons, March 9–13, 2005, New Orleans, LA.
https://doi.org/10.1053/j.jfas.2005.12.011Get rights and content

Medical records were reviewed for 90 patients (101 amputations) (mean age 64.3 years, range 39 to 86 years) who underwent transmetatarsal amputation (TMA). The mean follow-up period, excluding those patients who either died or went on to a more proximal amputation less than 6 months after TMA, was 2.1 years. Patients were examined for any postoperative complications associated with TMA. Complications were defined as hospital mortality occurring less than 30 days postoperatively; stump infarction with or without more proximal amputation; postoperative infection; chronic stump ulceration; stump deformity in any of 3 cardinal planes; wound dehiscence; equinus and calcaneus gait. An uncomplicated outcome was defined as the absence of all these complications and an ability to walk on the residuum with a diabetic shoe and filler after a minimum follow-up of 6 months. The χ2 tests of association were used to determine whether diabetes, a palpable pedal pulse, coronary artery disease, end-stage renal disease, cerebral vascular accident, or hypertension were predictive of or associated with healing. A documented palpable pedal pulse was a predictor of healing (P = .0567) and of not requiring more proximal amputation (P = .03). End-stage renal disease predicted nonhealing (P = .04). A healed stump was achieved in 58 cases (57.4%). Postsurgical complications developed in 88 cases (87.1%). Two patients died within 30 days postoperatively. These data suggest that TMA is associated with high complication rates in a diabetic and vasculopathic population.

Section snippets

Materials and Methods

Medical charts and electronic databases were retrospectively reviewed for 108 patients seen consecutively for TMA. Surgery was performed by the senior authors at Kaiser Permanente Oakland, Richmond, and Walnut Creek, between April 1993 and January 2004. Outcome assessments were performed by the senior authors at the last documented office visit.

Indications for surgery were chronic forefoot ulceration (Fig 1A), forefoot infection, forefoot gangrene (Fig 1B), or a combination of these (Table 1).

Results

Demographic characteristics and risk factors for the TMA surgery cohort are shown in Table 2. Mean postoperative follow-up, excluding patients who died or went on to a more proximal amputation less than 6 months after TMA, was 2.1 years. The TMA was done in 101 feet for 91 patients (78 men, 23 women with mean age of 64.3 years [range 39 to 86 years]).

Palpable pedal pulses were noted in 34 patients. Of patients without a palpable pulse, 36 had an audible Doppler signal. Mean ABI was 0.73 (range

Discussion

Bernard and Heute first described TMA in 1855 for treatment of trenchfoot. However, the TMA limb salvage procedure was not popularized until 1949, when McKittrick and colleagues (8) first reported a series of 215 TMA procedures done to treat infection or gangrene in patients with diabetes mellitus. These investigators reported a healing rate of 72%, a 12.5% rate of amputation higher on the limb, postoperative hospital stay of 30 days, and a 0.9% rate of hospital mortality within 30 days after

Conclusion

The current study describes morbidity and mortality after TMA in a large population of diabetic and vasculopathic patients. The diagnosis of ESRD was found to be a statistically significant predictor for failure to heal. Patients with a palpable pedal pulse had statistically significant predictable healing as well as not requiring a more proximal amputation. Therefore, we believe that these factors should be considered when counseling patients about potential risks and benefits of TMA.

Acknowledgments

Kaiser Permanente Division of Research Biostatistician and Investigator Mary Anne Armstrong, MA, provided statistical consultation, and Yun-Yi Hung, PhD, Programmer, ran all the analyses. The Kaiser Permanente Medical Editing Department provided editorial review and assistance.

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  • Cited by (95)

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    1

    Department of Orthopedics and Podiatric Surgery, Kaiser Permanente Medical Center, Oakland and Richmond, CA; Second-Year Resident, San Francisco Bay Area Foot and Ankle Residency Program, San Francisco, CA

    2

    Department of Orthopedics and Podiatric Surgery, Kaiser Permanente Medical Center, Oakland and Richmond, CA; Staff Podiatric Surgeon, Attending Staff, San Francisco Bay Area Foot and Ankle Residency Program, San Francisco, CA

    3

    Department of Orthopedics and Podiatric Surgery, Kaiser Permanente Medical Center, Walnut Creek, CA; Staff Podiatric Surgeon, Attending Staff, San Francisco Bay Area Foot and Ankle Residency Program, San Francisco, CA

    4

    Department of Orthopedics and Podiatric Surgery, Kaiser Permanente Medical Center, Oakland and Richmond, CA; Staff Podiatric Surgeon, Attending Staff, San Francisco Bay Area Foot and Ankle Residency Program, San Francisco, CA

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