Transmetatarsal David J.
Effeney, MB, BS, FRACS;
Robert C.
Amputation
Lim, MD; William P. Schecter, MD
\s=b\ We have reviewed the records of 25 patients who underwent transmetatarsal amputation at San Francisco General Hospital. The average patient age was 63 years old. Twelve of the patients were diabetic, while transmetatarsal amputations were performed in eleven with simple arteriosclerosis. Two patients underwent amputations for either trauma or nonhealing ulcer. Thirteen of the patients healed their amputation, and twelve of these became ambulatory. Eleven required higher amputation, because of nonhealing due to infection in seven and progressive ischemia in four. One patient died on the first postoperative day of pneumonia. The failure group was younger, contained more diabetics, and had a higher incidence of infection. The operative procedure of transmetatarsal amputation is described. We believe that patients with distal gangrene without spreading infection should be considered for transmetatarsal amputation, reserving initial below-knee amputation for those with greater involvement of the foot. a
(Arch Surg 112:1366-1370, 1977) classic indications for amputation have varied little since the dawn of history; thus, at times, the only treatment for trauma, infection, tumor, or ischemia is removal of the limb. With the progressive aging of our civilian populations and a concomitant increase in arterial diseases, 90% of all amputations today are carried out for ischemie or infective gangrene.1 The aims of amputation, to remove dead tissue, relieve pain, obtain healing, and rehabilitate the patient to walking,- must be kept in mind when selecting the level of amputation. In all decisions, the more predictable healing of proximal amputation must be weighed against the rehabilitation advantages of a distally removed stump. The optimal level of amputation has been lowered in recent years from above-knee to the below-knee level1:3·4; however, in a small group of patients with distal gangrene, a transmetatarsal amputation may be applic¬ able. Transmetatarsal amputation (TMA), first described in 1855 by Bernard and Heute,5 has found little favor in the recent literature and has had limited acceptance and use. A 1949 report by McKittrick et al6 described an approach to the management of distal gangrene in diabetics with combined antibiotic and surgical therapy. Two thirds of their patients were considered to have satisfactory results. Many reports have appeared since then, the largest being the collected series of Wheelock,7 in which transmetatarsal amputations were studied. Sixty-three percent of these patients had healed amputation stumps two years after operation. Schwindt et al* recently reported 92 transmeta-
The
for publication July 5, 1977. From the Department of Surgery, University of California at San Francisco General Hospital. Read before the 25th scientific meeting of the International Cardiovascular Society, Rochester, NY, June 16, 1977. Reprint requests to Department of Surgery, San Francisco General Hospital, 1001 Potrero Ave, San Francisco, CA 94110 (Dr Effeney).
Accepted
tarsal amputations performed on patients for gangrene or infective processes of the toes. They found the transmeta¬ tarsal amputation to be more successful in diabetics, although the healing time was prolonged. If successful, this level of amputation provides the patient with a functional, weight-bearing stump without the need for a prosthesis. SUBJECTS AND METHODS
Twenty-five patients who had undergone a transmetatarsal amputation between January 1970 and June 1976 were included in the study. The hospital inpatient and clinical records were exam¬ ined and private files were consulted as appropriate. All patients were evaluated according to a fixed protocol for diabetes, periph¬ eral pulse status, preexisting infection, trophic changes, and pain. The status of previous amputation, sympathectomy, or reconstruc¬ tive vascular surgery was noted. All patients were treated conser¬ vatively for a period of time ranging from days to weeks prior to the amputation. The usual indications for transmetatarsal ampu¬ tation of gangrene of one or more toes, with or without soft tissue infection or osteomyelitis, were in general observed. On a few occasions, however, patients with a small area of gangrenous extension on the dorsum of the foot were treated by transmeta¬ tarsal amputation. Those patients with progressive gangrene or uncontrolled infection where there was considerable extension of disease into the foot were recommended for higher amputation.
Surgical Technique Preoperative.—The value of transmetatarsal amputation is predi¬ cated on the goal of creating an amputation stump that allows for the normal weight-bearing by the leg. Patient selection is of the utmost importance, with careful adherence to the indications, critical assessment of the circulation to the foot, and appropriate preoperative treatment. Two to three weeks of intensive hospital care may be necessary to control infection. The therapeutic regimen employed during this time includes strict bedrest, local management of the infection and gangrene, including, if neces¬ sary incision and drainage of localized pus, and systemic antibiotic therapy. The leg is not shaved, but is washed with antiseptic soap during the 72 hours preceding TMA. Operative.—Regional or general anesthesia may be used. The patient should be positioned supine on the operating table. The entire lower leg is prepared aseptically, the foot being prepared last. The preparation and initial draping should always leave the leg exposed, so that, if findings at operation prove a higher amputation essential, one can proceed more proximally. Tubular stockinette is used to drape the extremity. No tourniquet is used. An assistant holds the toes to prevent contamination of other members of the operating team. When the specimen has been removed, that assistant must regown and reglove. The skin incision should be outlined to create a generous plantar flap. This flap can be trimmed later should it be too long. The dorsal part of the incision should be made in a transverse direction at the level of the proximal metatarsus, just beyond the heads, and carried to bone (Fig 1). No dorsal flap is created. The incision extends from the midpoint on the medial aspect to midpoint on the lateral side of the forefoot and is continued distally along that line. On the plantar surface the incision is continued just proximal to the metatarsophalangeal crease, from medial to lateral, down to
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the bone. The metatarsals are divided by bone cutters and the tendons are pulled down and transected sharply as high as possible (Fig 2 and 3). The bony ends are carefully rounded smooth with a fine double-action rongeur (Fig 4). Meticulous hemostasis is obtained. The tissue must be handled with great care, without the use of tissue forceps, and dissection is carried out using sharp technique. The plantar skin flap should be trimmed, and any remaining tendons or muscular structures removed. The volar plates that are avascular are excised (Fig 5). The skin is closed with accurate approximation without tension, using fine interrupted monofilament nylon or stainless steel wire sutures (Fig 6). The dog ears are not exised, as they atrophy and they may provide important blood supply to the flap. Drainage of the wound is not required. The wound is dressed with gauze and fluffs. The amputation stump is then immobilized with a light plaster cast or splint carried to the upper calf level. Postoperative.—The patient is supported in bed in a neutral position and the pressure points protected. The wound is inspected ten days postoperatively. Half of the sutures are removed when epithelization of the wound appears intact, and the remaining half, two to four days later. Mobilization is then commenced, but full weight-bearing is not permitted for four to six weeks. Antibiotic therapy is continued through the perioperative and
early postoperative period. Following transmetatarsal amputation, the progress of rehabil¬ itation is usually uncomplicated when healing is assured. No prosthesis is required. However, the insertion of a toe block to prevent buckling of the toe of the shoe, and a steel shank in the sole of the shoe are advised to the step.
give spring to
prevent excessive dorsiflexion and
RESULTS
Twenty-three patients underwent transmetatarsal am¬ putation for ischemie or infective gangrene. Twelve of these patients were diabetic, while 11 patients had simple arteriosclerosis. A 68-year-old man underwent a contami¬ nated traumatic amputation of the toes converted to a TMA, and a 35-year-old man underwent TMA for nonhealing ulcer following a burn. One patient died of pneumonia on the first postoperative day. Thirteen patients healed their amputation, while 11 required further amputation, initially below the knee. A 46-year-old diabetic patient who had refused below-knee amputation was treated initially with TMA, which failed. He subsequently underwent above-knee amputation. The pertinent clinical information at the time of opera¬
tion is summarized in Tables 1 and 2. Table 3 lists the indication for operation in each group, and Table 4 summa¬ rizes the outcome and follow-up of the patients. The patients in the successful group were hospitalized an average of 37 days (range, 18 to 65). Those achieving
primary healing were discharged earlier, averaging 34 days postoperatively (range, 18 to 65), than those patients whose wounds healed by second intention, whose hospital stay averaged 43 days (range, 22 to 60). Those whose amputations failed had a significantly longer hospital course of 51 days (range, 21 to 120). COMMENT
The overall success rate of 54% in our series is compar¬ able with other published series.6" A higher failure rate was noted in diabetics who underwent transmetatarsal
amputation. This is
in agreement with the reports of Haimovici" and Bradham et al,1" and differs from the equal success rate reported by Warren et al" and the higher rate of success in diabetics in the report of Schwindt et al.8 Diabetes was meticulously controlled in all the patients in the current series. The failure group was notably younger and had under¬ gone more attempts to improve the blood supply of the limb by vascular reconstruction and sympathectomy. They had undergone more contralateral below-knee amputa¬ tions, although the number of previous digital amputations was the same in the healed and failed group. The pulse status of the groups confirmed that, although the absence of a distal pulse does not preclude a successful result, the presence of a pedal pulse is a favorable prognostic sign. None of the patients with palpable pedal pulses failed to heal their TMA wound. In the few instances in which we have used Doppler blood flow assessment, ankle blood pressure measurements in excess of 50% of the brachial systolic pressure were associated with a good result. Baker and Barnes1- reported on 57 patients with toe or metatarsal amputations who were assessed in this way. None of the amputations healed if the ankle blood pressure was less than 60 mm Hg. Verta and associates," on the other hand, obtained healing of transmetatarsal amputations with an ankle blood pressure as low as 40 mm Hg. They state, however, that attempted salvage of the foot may be futile if the ankle blood pressure is less than 35 mm Hg. Jamieson and Hill2 point out that a trial of TMA may be the only investigation that will indicate that healing will occur, especially in patients with a gradient from the ankle to the forefoot in whom the ankle blood pressure would not be a good predictor of local ischemia. The major limiting factor of transmetatarsal amputa¬ tion is infection. It is often difficult to differentiate clinically between infection and ischemia, and usually the two coexist. We have ascribed the failure of TMA predom¬ inantly to ischemia in four patients, and infection in seven. We believe that spreading cellulitis or infection in tendon sheaths must be adequately controlled and treated, if necessary by open drainage and antibiotics prior to surgery.6'11 Failure to control infection is an absolute contraindication to transmetatarsal amputation. Preopera¬ tive and postoperative antibiotics cover should be given. The antibiotics should be based on culture and sensitivity and should be initiated a minimum of one to two days
preoperatively.
In the past, amputations have been delegated to the junior members of a surgical team.1 There can be no in logic the continuance of the practice of using amputa¬ tion surgery as a surgical "proving ground," when the operative technique of transmetatarsal amputation is so critical to the success of the surgery. The first formal description was followed by that of McKittrick et al,6 and others'"10·14 subsequently reported on modifications of the technique. Proper preparation of the patient and gentle handling of the tissue with a "no-touch" technique will achieve a well-healed stump in appropriate cases. We do not use drains as a matter of policy and do not more
'
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Fig 1.—Line
of skin incision: incision is carried down to bone.
Fig 3.—Tendons are drawn down possible, and allowed to retract.
and transected
as
high
Fig 2.—Metatarsals
as
Fig
4—Divided
Fig 5.—Flap
are
divided at their necks.
bony ends
are
rounded
is trimmed and volar
plates
Fig 6.—Skin is approximated without
used.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/10/2015
using
fine rongeurs.
excised.
tension. No drains
are
Table 1.—Patient Status at
Operation
Healed TMA*
(
=
13)
Failed TMA
(
=
12)
Average age, yr
63.6
58.9
Diabetes Juvenile Adult-onset Pulse status Femoral
13
12
of the failure group did not walk, all but one of our successful group, a man who had suffered a stroke, were ambulatory. The patients required no prosthesis except for rubber padding and a steel shank in the usual shoe. The energy requirements for ambulation are unchanged by TMA,2 and although some people prefer to use a cane, usually no limp is noticable. This study was supported in part by National Institutes of Health grants GM 18470 and GM 24033. Dr Effeney is the recipient of an Australian National Heart Foundation Overseas Clinical Fellowship. The figures are reproduced with the permission of Year Book Medical Publishers Ine,
Popliteal Pedal
Chicago.
"Transmetatarsal amputation.
References Table 2.—Previous
Surgery No. of Patients
Healed TMA*
Failed TMA
Sympathectomy Reconstructions
Amputations
Below-knee
Digital "Transmetatarsal amputation.
Table 3.—Indications for Transmetatarsal
Amputation
(TMA) Healed TMA
(N
=
13)
Failed TMA
(N
=
12)
Dry
gangrene Failed toe amputation Nonhealing ulcer Infection Wet gangrene Trauma
Table 4.—Fate of Patients
Undergoing Amputation (TMA)
Transmetatarsal
No. of Patients Healed TMA
Failed TMA
13
12
Primary healing Secondary healing Infection Ischemia
Death Total
1. Little JM: Amputation of the leg: A dull topic revisited. Med J Aust 1973. 2. Jamieson W, Hill D: Amputation for vascular disease. Br J Surg 63:683-690, 1976. 3. Lim RC, Blaisdell FW, Hall AD, et al: Below-knee amputations for ischemic gangrene. Surg Gynecol Obstet 124:493, 1967. 4. Warren R, Kihn R: A survey of lower extremity amputations for ischemia. Surgery 68:107-120, 1968. 5. Bernard C, Huete C, quoted by Schwindt CD, Lulloff RS, Rogers SC: Transmetatarsal amputation. Orthop Clin North Am 4:31-42, 1973. 6. McKittrick LE, McKittrick JB, Risley TS: Transmetatarsal amputation for infection or gangrene in patients with diabetes mellitus. Ann Surg 130:826-842, 1949. 7. Wheelock FC: Transmetatarsal amputations and arterial surgery in diabetic patients. N Engl J Med 264:316-320, 1961. 8. Schwindt CD, Lulloff RS, Rogers SC: Transmetatarsal amputations. Orthop Clin North Am 4:31-42, 1973. 9. Haimovici H: Criteria for and results of transmetatarsal amputation for ischemic gangrene. Arch Surg 70:45-51, 1955. 10. Bradham GB, Lee WH, Stallworth JM: Transmetatarsal amputation. Angiology 11:495-498, 1960. 11. Warren R, Crawford ES, Hardy IB, et al: The transmetatarsal amputation in arterial deficiency of the lower extremity. Surgery 31:132\x=req-\ 140, 1952. 12. Baker WH, Barnes RU: Minor forefoot amputation in patients with low ankle pressure. Am J Surg 153:331-332, 1977. 13. Verta MJ, Gross WS, Van Bellen B, et al: Forefoot perfusion pressure and minor amputation for gangrene. Surgery 80:729-734, 1976. 14. Haimovici H: Transmetatarsal amputation of the foot, in Haimovici H (ed): Vascular Surgery: Principles and Techniques. New York, McGraw\x=req-\ Hill Book Co Inc, 1976, chap 58.
2:442-445,
leave wounds open to secondary closure, except under unusual circumstances, when infection, rather than ischemia, is the primary problem. The marginally viable flap on the amputation stump will heal if good epithelial approximation is done, but will necrose if left open or unsupported by adjacent viable tissue. The hospital stay of these patients is prolonged, the time in most reports ranging from 4 to 12 weeks. This, however, is shorter than the time spent by a below-knee amputee, whether or not a prosthesis is fitted.14 Whereas two thirds
Discussion Frank H. Leeds, MD, San Francisco: Although the patients undergoing transmetatarsal amputation are a small part of the total amputation group, only 3% of the total amputations I have done, it is still a very important segment, because the potential for rehabilitation is so good. In 1949, I became interested in this problem after reading McKittrick's classic article, in which he stressed so many of the points that Dr Effeney and his colleagues have so beautifully pointed out concerning the technique of the operation and the preparation of the patient. There are two problems I want to address myself to that have been stressed here. The first is that infection must be completely controlled before a transmetatarsal amputation can succeed. This requires prolonged hospitalization. I don't know what your prob¬ lems are, but mine is the Utilization Committee-I am finally getting them educated. They now realize that these patients need a long time in the hospital to be prepared for operation, and a long time postoperatively to heal. However, under the right conditions, 90% of these patients should heal primarily or some with small healing defects that, as Dr Effeney and his colleagues have pointed out, close in secondarily. How to pick these patients? This is what I addressed myself to in company with Dr Freeman and Dr Gilfillin many years ago. In 1954, I presented a paper to this society in which I discussed this
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topic,
how to evaluate the patient with ischemia by some quanti¬ tative test. At that time, I described a reactive hyperemia test where the feet are blanched by application of a tourniquet at the ankle, raised to 65 cm above heart level, the tourniquet released, and then the feet are gradually lowered in decrements of 5 cm. A ,photoflood light is necessary to accurately see the return of reactive hyperemia. If the reactive hyperemia appears at 45 cm above heart level or higher, the great majority of these amputa¬ tions will heal. This test, in my hands and those of my group, has been very useful. We have found it to be better than the Doppler ankle pressure index in evaluating the potential for healing of a transmetatarsal amputation. I must commend Dr Effeney and his colleagues for pointing out that successful transmetatarsal amputation requires that infec¬ tion be completely controlled, the meticulous "no-touch" technique must be adhered to, and to this I will add that if we can select patients properly, 90% will heal. The question that I would like to ask is, as you follow up these patients, how many of the amputa¬ tions have held up, without need for converting them to a higher level? Jerry Goldstone, MD, San Francisco: Once again, Dr Effeney and his associates have made a significant presentation regarding amputation. Their interest in this subject goes back well over 12 years, and I believe that their work has been a major factor in the emergence of the below-knee amputation as the most common for peripheral vascular disease. Now, they are advocating a still more distal amputation, namely, transmetatarsal. This report serves as a reminder of the general principles of amputation, that is, to preserve the maximum length consistent with a high likelihood of primary healing, combined with ease of prosthetic fitting to provide maximum rehabilitation potential. The advantages of the transmetatarsal amputation are its excel¬ lent functional result, minimal disability, and lack of formal prosthetic requirement. It is the ideal amputation level if several toes or the great toe are involved in an ischemie or infectious process. Its disadvantage is the risk of nonhealing, necessitating
secondary amputation. The series presented today, with nearly 50% failures, suggest that this risk is very high indeed. The fundamental question, as stated by the authors and by Dr Leeds, is, how can a more acceptable rate of primary healing be achieved? The authors have stressed the importance of meticulous surgical technique. Knowing from close personal contact that they are superb clinical surgeons, I
am confident that none of their failures were technical. of clinical criteria such as the lowest palpable pulse, angiographie findings, skin temperature, reactive hyperemia (as mentioned by Dr Leeds), and other tests have not proved to be reliable predictors of healing. Recently, the measurement of ankle or forefoot blood pressures have been reported at these meetings and elsewhere to be helpful, especially when no arterial velocity signal is detectable with a Doppler probe. The authors' report indicated that they used Doppler flow assessment in a few instances. I would like to know in how many, and are they now using it routinely as an adjunct to influence their clinical decision? We have continued to use the xenon 133 washout technique to determine skin blood flow at proposed amputation levels, since the critical tissue for amputation healing and stump function is the skin. As described by Wes Moore, a xenon clearance of at least 2.7 ml/100 gm of tissue per minute correlates with virtually a 100% healing rate. We perform amputation at the most distal level where there is absence of infection and a xenon clearance of this magnitude. It is a rather simple procedure and can easily be performed in the nuclear medicine department of most hospi¬ tals. Perusal of this report has brought several other questions to
The
use
mind. First, how many of their patients had dependent rubor? We believe that dependent rubor at the level of the skin incision is an almost absolute contraindication to amputation at that level. Second, what was the morbidity in those patients who failed to heal their transmetatarsal amputations? Third, how many major lower extremity amputations were done at San Francisco General Hospital for the same indications and during the same time period? In other words, what percentage of patients in this category would they expect to be TMA candidates? Finally, why did two thirds of the failures in their series not walk, and what were their subsequent amputational levels? If TMA is not feasible, we now prefer the Syme's to the standard below-knee and have had nearly uniform success in a small series. Steven Dosick, MD, Toledo, Ohio: In keeping with this fine report, on the conservation of the patient's limb, we at the Medical College of Ohio have recently received what the prognosis is on those patients who undergo amputations. If you can keep a patient's leg so that he can walk to the bathroom, the families are often willing to keep their elderly family members. This seems to be the most important factor. Once they can no longer reach the bathroom and a bedpan must be used, they tend to go to a nursing home. Transmetatarsal amputations and bypass surgery that conserves a foot is a big factor in the ambulation. The patients who do go to the nursing home, whether it is due to the nursing home or the severity of the disease process, often die within six months. Sam Mellick, MD, Queensland, Australia: I would like to commend the presenter of this report for reminding us that, although quite rightly, below-knee amputation is the favored procedure for most distal gangrene, there is still a place for the operation described today. I think a lot of us forgot it for a while, but there is no doubt that in order to get good results with it, one has to be tremendously patient and have patients who are prepared to put up with a great deal of postoperative pain. I do not think it has been stressed yet, but there is no comparison in the postoperative course between a proximal and a distal amputation. Whether it is related to multiple bone sections as opposed to just one or two proximally, I don't know. But our patients who have undergone this procedure have had a very painful course postoperatively, and I think this has to be stressed to the patient. I wonder if I might ask the author about a couple of the technical points. He has stated that drainage is absolutely avoided. I think it should be employed. Second, he has sutured the skin. I wonder if he would comment on the use of no sutures, but just adhesive strips in a further attempt to avoid completely any damage to the anterior
flap.
Dr Lim: To answer Dr Leeds, we agree with him that control of infection is necessary to insure success. In our report, we gave complete credit to Dr McKittrick and Dr Wheelock in pioneering this procedure. To answer Dr Goldstone's questions, the use of the xenon clearance, as Dr Moore and he have utilized in defining the level of amputation, is a very good one. As more experience is gained, it would probably be a very accurate way to determine amputation levels, even at the foot level. As far as rubor is concerned, it is a contraindication in performing this amputation. In all of the patients who successfully heal their amputation, there were no failures in ambulations. In regard to the transmetatarsal amputation as compared to the total number of amputations done at our institution, it is a small number and is comparable to what Dr Leeds mentioned. As far as drainage is concerned, we have not drained any amputation done for ischemie disease. There has been no problem in terms of hematoma or fluid collection in any of these amputations. We do utilize adhesive strips in selected cases and I think it is a good atraumatic way to close the wound.
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Effeney, MB, BS, FRACS;
Robert C.
Amputation
Lim, MD; William P. Schecter, MD
\s=b\ We have reviewed the records of 25 patients who underwent transmetatarsal amputation at San Francisco General Hospital. The average patient age was 63 years old. Twelve of the patients were diabetic, while transmetatarsal amputations were performed in eleven with simple arteriosclerosis. Two patients underwent amputations for either trauma or nonhealing ulcer. Thirteen of the patients healed their amputation, and twelve of these became ambulatory. Eleven required higher amputation, because of nonhealing due to infection in seven and progressive ischemia in four. One patient died on the first postoperative day of pneumonia. The failure group was younger, contained more diabetics, and had a higher incidence of infection. The operative procedure of transmetatarsal amputation is described. We believe that patients with distal gangrene without spreading infection should be considered for transmetatarsal amputation, reserving initial below-knee amputation for those with greater involvement of the foot. a
(Arch Surg 112:1366-1370, 1977) classic indications for amputation have varied little since the dawn of history; thus, at times, the only treatment for trauma, infection, tumor, or ischemia is removal of the limb. With the progressive aging of our civilian populations and a concomitant increase in arterial diseases, 90% of all amputations today are carried out for ischemie or infective gangrene.1 The aims of amputation, to remove dead tissue, relieve pain, obtain healing, and rehabilitate the patient to walking,- must be kept in mind when selecting the level of amputation. In all decisions, the more predictable healing of proximal amputation must be weighed against the rehabilitation advantages of a distally removed stump. The optimal level of amputation has been lowered in recent years from above-knee to the below-knee level1:3·4; however, in a small group of patients with distal gangrene, a transmetatarsal amputation may be applic¬ able. Transmetatarsal amputation (TMA), first described in 1855 by Bernard and Heute,5 has found little favor in the recent literature and has had limited acceptance and use. A 1949 report by McKittrick et al6 described an approach to the management of distal gangrene in diabetics with combined antibiotic and surgical therapy. Two thirds of their patients were considered to have satisfactory results. Many reports have appeared since then, the largest being the collected series of Wheelock,7 in which transmetatarsal amputations were studied. Sixty-three percent of these patients had healed amputation stumps two years after operation. Schwindt et al* recently reported 92 transmeta-
The
for publication July 5, 1977. From the Department of Surgery, University of California at San Francisco General Hospital. Read before the 25th scientific meeting of the International Cardiovascular Society, Rochester, NY, June 16, 1977. Reprint requests to Department of Surgery, San Francisco General Hospital, 1001 Potrero Ave, San Francisco, CA 94110 (Dr Effeney).
Accepted
tarsal amputations performed on patients for gangrene or infective processes of the toes. They found the transmeta¬ tarsal amputation to be more successful in diabetics, although the healing time was prolonged. If successful, this level of amputation provides the patient with a functional, weight-bearing stump without the need for a prosthesis. SUBJECTS AND METHODS
Twenty-five patients who had undergone a transmetatarsal amputation between January 1970 and June 1976 were included in the study. The hospital inpatient and clinical records were exam¬ ined and private files were consulted as appropriate. All patients were evaluated according to a fixed protocol for diabetes, periph¬ eral pulse status, preexisting infection, trophic changes, and pain. The status of previous amputation, sympathectomy, or reconstruc¬ tive vascular surgery was noted. All patients were treated conser¬ vatively for a period of time ranging from days to weeks prior to the amputation. The usual indications for transmetatarsal ampu¬ tation of gangrene of one or more toes, with or without soft tissue infection or osteomyelitis, were in general observed. On a few occasions, however, patients with a small area of gangrenous extension on the dorsum of the foot were treated by transmeta¬ tarsal amputation. Those patients with progressive gangrene or uncontrolled infection where there was considerable extension of disease into the foot were recommended for higher amputation.
Surgical Technique Preoperative.—The value of transmetatarsal amputation is predi¬ cated on the goal of creating an amputation stump that allows for the normal weight-bearing by the leg. Patient selection is of the utmost importance, with careful adherence to the indications, critical assessment of the circulation to the foot, and appropriate preoperative treatment. Two to three weeks of intensive hospital care may be necessary to control infection. The therapeutic regimen employed during this time includes strict bedrest, local management of the infection and gangrene, including, if neces¬ sary incision and drainage of localized pus, and systemic antibiotic therapy. The leg is not shaved, but is washed with antiseptic soap during the 72 hours preceding TMA. Operative.—Regional or general anesthesia may be used. The patient should be positioned supine on the operating table. The entire lower leg is prepared aseptically, the foot being prepared last. The preparation and initial draping should always leave the leg exposed, so that, if findings at operation prove a higher amputation essential, one can proceed more proximally. Tubular stockinette is used to drape the extremity. No tourniquet is used. An assistant holds the toes to prevent contamination of other members of the operating team. When the specimen has been removed, that assistant must regown and reglove. The skin incision should be outlined to create a generous plantar flap. This flap can be trimmed later should it be too long. The dorsal part of the incision should be made in a transverse direction at the level of the proximal metatarsus, just beyond the heads, and carried to bone (Fig 1). No dorsal flap is created. The incision extends from the midpoint on the medial aspect to midpoint on the lateral side of the forefoot and is continued distally along that line. On the plantar surface the incision is continued just proximal to the metatarsophalangeal crease, from medial to lateral, down to
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the bone. The metatarsals are divided by bone cutters and the tendons are pulled down and transected sharply as high as possible (Fig 2 and 3). The bony ends are carefully rounded smooth with a fine double-action rongeur (Fig 4). Meticulous hemostasis is obtained. The tissue must be handled with great care, without the use of tissue forceps, and dissection is carried out using sharp technique. The plantar skin flap should be trimmed, and any remaining tendons or muscular structures removed. The volar plates that are avascular are excised (Fig 5). The skin is closed with accurate approximation without tension, using fine interrupted monofilament nylon or stainless steel wire sutures (Fig 6). The dog ears are not exised, as they atrophy and they may provide important blood supply to the flap. Drainage of the wound is not required. The wound is dressed with gauze and fluffs. The amputation stump is then immobilized with a light plaster cast or splint carried to the upper calf level. Postoperative.—The patient is supported in bed in a neutral position and the pressure points protected. The wound is inspected ten days postoperatively. Half of the sutures are removed when epithelization of the wound appears intact, and the remaining half, two to four days later. Mobilization is then commenced, but full weight-bearing is not permitted for four to six weeks. Antibiotic therapy is continued through the perioperative and
early postoperative period. Following transmetatarsal amputation, the progress of rehabil¬ itation is usually uncomplicated when healing is assured. No prosthesis is required. However, the insertion of a toe block to prevent buckling of the toe of the shoe, and a steel shank in the sole of the shoe are advised to the step.
give spring to
prevent excessive dorsiflexion and
RESULTS
Twenty-three patients underwent transmetatarsal am¬ putation for ischemie or infective gangrene. Twelve of these patients were diabetic, while 11 patients had simple arteriosclerosis. A 68-year-old man underwent a contami¬ nated traumatic amputation of the toes converted to a TMA, and a 35-year-old man underwent TMA for nonhealing ulcer following a burn. One patient died of pneumonia on the first postoperative day. Thirteen patients healed their amputation, while 11 required further amputation, initially below the knee. A 46-year-old diabetic patient who had refused below-knee amputation was treated initially with TMA, which failed. He subsequently underwent above-knee amputation. The pertinent clinical information at the time of opera¬
tion is summarized in Tables 1 and 2. Table 3 lists the indication for operation in each group, and Table 4 summa¬ rizes the outcome and follow-up of the patients. The patients in the successful group were hospitalized an average of 37 days (range, 18 to 65). Those achieving
primary healing were discharged earlier, averaging 34 days postoperatively (range, 18 to 65), than those patients whose wounds healed by second intention, whose hospital stay averaged 43 days (range, 22 to 60). Those whose amputations failed had a significantly longer hospital course of 51 days (range, 21 to 120). COMMENT
The overall success rate of 54% in our series is compar¬ able with other published series.6" A higher failure rate was noted in diabetics who underwent transmetatarsal
amputation. This is
in agreement with the reports of Haimovici" and Bradham et al,1" and differs from the equal success rate reported by Warren et al" and the higher rate of success in diabetics in the report of Schwindt et al.8 Diabetes was meticulously controlled in all the patients in the current series. The failure group was notably younger and had under¬ gone more attempts to improve the blood supply of the limb by vascular reconstruction and sympathectomy. They had undergone more contralateral below-knee amputa¬ tions, although the number of previous digital amputations was the same in the healed and failed group. The pulse status of the groups confirmed that, although the absence of a distal pulse does not preclude a successful result, the presence of a pedal pulse is a favorable prognostic sign. None of the patients with palpable pedal pulses failed to heal their TMA wound. In the few instances in which we have used Doppler blood flow assessment, ankle blood pressure measurements in excess of 50% of the brachial systolic pressure were associated with a good result. Baker and Barnes1- reported on 57 patients with toe or metatarsal amputations who were assessed in this way. None of the amputations healed if the ankle blood pressure was less than 60 mm Hg. Verta and associates," on the other hand, obtained healing of transmetatarsal amputations with an ankle blood pressure as low as 40 mm Hg. They state, however, that attempted salvage of the foot may be futile if the ankle blood pressure is less than 35 mm Hg. Jamieson and Hill2 point out that a trial of TMA may be the only investigation that will indicate that healing will occur, especially in patients with a gradient from the ankle to the forefoot in whom the ankle blood pressure would not be a good predictor of local ischemia. The major limiting factor of transmetatarsal amputa¬ tion is infection. It is often difficult to differentiate clinically between infection and ischemia, and usually the two coexist. We have ascribed the failure of TMA predom¬ inantly to ischemia in four patients, and infection in seven. We believe that spreading cellulitis or infection in tendon sheaths must be adequately controlled and treated, if necessary by open drainage and antibiotics prior to surgery.6'11 Failure to control infection is an absolute contraindication to transmetatarsal amputation. Preopera¬ tive and postoperative antibiotics cover should be given. The antibiotics should be based on culture and sensitivity and should be initiated a minimum of one to two days
preoperatively.
In the past, amputations have been delegated to the junior members of a surgical team.1 There can be no in logic the continuance of the practice of using amputa¬ tion surgery as a surgical "proving ground," when the operative technique of transmetatarsal amputation is so critical to the success of the surgery. The first formal description was followed by that of McKittrick et al,6 and others'"10·14 subsequently reported on modifications of the technique. Proper preparation of the patient and gentle handling of the tissue with a "no-touch" technique will achieve a well-healed stump in appropriate cases. We do not use drains as a matter of policy and do not more
'
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Fig 1.—Line
of skin incision: incision is carried down to bone.
Fig 3.—Tendons are drawn down possible, and allowed to retract.
and transected
as
high
Fig 2.—Metatarsals
as
Fig
4—Divided
Fig 5.—Flap
are
divided at their necks.
bony ends
are
rounded
is trimmed and volar
plates
Fig 6.—Skin is approximated without
used.
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using
fine rongeurs.
excised.
tension. No drains
are
Table 1.—Patient Status at
Operation
Healed TMA*
(
=
13)
Failed TMA
(
=
12)
Average age, yr
63.6
58.9
Diabetes Juvenile Adult-onset Pulse status Femoral
13
12
of the failure group did not walk, all but one of our successful group, a man who had suffered a stroke, were ambulatory. The patients required no prosthesis except for rubber padding and a steel shank in the usual shoe. The energy requirements for ambulation are unchanged by TMA,2 and although some people prefer to use a cane, usually no limp is noticable. This study was supported in part by National Institutes of Health grants GM 18470 and GM 24033. Dr Effeney is the recipient of an Australian National Heart Foundation Overseas Clinical Fellowship. The figures are reproduced with the permission of Year Book Medical Publishers Ine,
Popliteal Pedal
Chicago.
"Transmetatarsal amputation.
References Table 2.—Previous
Surgery No. of Patients
Healed TMA*
Failed TMA
Sympathectomy Reconstructions
Amputations
Below-knee
Digital "Transmetatarsal amputation.
Table 3.—Indications for Transmetatarsal
Amputation
(TMA) Healed TMA
(N
=
13)
Failed TMA
(N
=
12)
Dry
gangrene Failed toe amputation Nonhealing ulcer Infection Wet gangrene Trauma
Table 4.—Fate of Patients
Undergoing Amputation (TMA)
Transmetatarsal
No. of Patients Healed TMA
Failed TMA
13
12
Primary healing Secondary healing Infection Ischemia
Death Total
1. Little JM: Amputation of the leg: A dull topic revisited. Med J Aust 1973. 2. Jamieson W, Hill D: Amputation for vascular disease. Br J Surg 63:683-690, 1976. 3. Lim RC, Blaisdell FW, Hall AD, et al: Below-knee amputations for ischemic gangrene. Surg Gynecol Obstet 124:493, 1967. 4. Warren R, Kihn R: A survey of lower extremity amputations for ischemia. Surgery 68:107-120, 1968. 5. Bernard C, Huete C, quoted by Schwindt CD, Lulloff RS, Rogers SC: Transmetatarsal amputation. Orthop Clin North Am 4:31-42, 1973. 6. McKittrick LE, McKittrick JB, Risley TS: Transmetatarsal amputation for infection or gangrene in patients with diabetes mellitus. Ann Surg 130:826-842, 1949. 7. Wheelock FC: Transmetatarsal amputations and arterial surgery in diabetic patients. N Engl J Med 264:316-320, 1961. 8. Schwindt CD, Lulloff RS, Rogers SC: Transmetatarsal amputations. Orthop Clin North Am 4:31-42, 1973. 9. Haimovici H: Criteria for and results of transmetatarsal amputation for ischemic gangrene. Arch Surg 70:45-51, 1955. 10. Bradham GB, Lee WH, Stallworth JM: Transmetatarsal amputation. Angiology 11:495-498, 1960. 11. Warren R, Crawford ES, Hardy IB, et al: The transmetatarsal amputation in arterial deficiency of the lower extremity. Surgery 31:132\x=req-\ 140, 1952. 12. Baker WH, Barnes RU: Minor forefoot amputation in patients with low ankle pressure. Am J Surg 153:331-332, 1977. 13. Verta MJ, Gross WS, Van Bellen B, et al: Forefoot perfusion pressure and minor amputation for gangrene. Surgery 80:729-734, 1976. 14. Haimovici H: Transmetatarsal amputation of the foot, in Haimovici H (ed): Vascular Surgery: Principles and Techniques. New York, McGraw\x=req-\ Hill Book Co Inc, 1976, chap 58.
2:442-445,
leave wounds open to secondary closure, except under unusual circumstances, when infection, rather than ischemia, is the primary problem. The marginally viable flap on the amputation stump will heal if good epithelial approximation is done, but will necrose if left open or unsupported by adjacent viable tissue. The hospital stay of these patients is prolonged, the time in most reports ranging from 4 to 12 weeks. This, however, is shorter than the time spent by a below-knee amputee, whether or not a prosthesis is fitted.14 Whereas two thirds
Discussion Frank H. Leeds, MD, San Francisco: Although the patients undergoing transmetatarsal amputation are a small part of the total amputation group, only 3% of the total amputations I have done, it is still a very important segment, because the potential for rehabilitation is so good. In 1949, I became interested in this problem after reading McKittrick's classic article, in which he stressed so many of the points that Dr Effeney and his colleagues have so beautifully pointed out concerning the technique of the operation and the preparation of the patient. There are two problems I want to address myself to that have been stressed here. The first is that infection must be completely controlled before a transmetatarsal amputation can succeed. This requires prolonged hospitalization. I don't know what your prob¬ lems are, but mine is the Utilization Committee-I am finally getting them educated. They now realize that these patients need a long time in the hospital to be prepared for operation, and a long time postoperatively to heal. However, under the right conditions, 90% of these patients should heal primarily or some with small healing defects that, as Dr Effeney and his colleagues have pointed out, close in secondarily. How to pick these patients? This is what I addressed myself to in company with Dr Freeman and Dr Gilfillin many years ago. In 1954, I presented a paper to this society in which I discussed this
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topic,
how to evaluate the patient with ischemia by some quanti¬ tative test. At that time, I described a reactive hyperemia test where the feet are blanched by application of a tourniquet at the ankle, raised to 65 cm above heart level, the tourniquet released, and then the feet are gradually lowered in decrements of 5 cm. A ,photoflood light is necessary to accurately see the return of reactive hyperemia. If the reactive hyperemia appears at 45 cm above heart level or higher, the great majority of these amputa¬ tions will heal. This test, in my hands and those of my group, has been very useful. We have found it to be better than the Doppler ankle pressure index in evaluating the potential for healing of a transmetatarsal amputation. I must commend Dr Effeney and his colleagues for pointing out that successful transmetatarsal amputation requires that infec¬ tion be completely controlled, the meticulous "no-touch" technique must be adhered to, and to this I will add that if we can select patients properly, 90% will heal. The question that I would like to ask is, as you follow up these patients, how many of the amputa¬ tions have held up, without need for converting them to a higher level? Jerry Goldstone, MD, San Francisco: Once again, Dr Effeney and his associates have made a significant presentation regarding amputation. Their interest in this subject goes back well over 12 years, and I believe that their work has been a major factor in the emergence of the below-knee amputation as the most common for peripheral vascular disease. Now, they are advocating a still more distal amputation, namely, transmetatarsal. This report serves as a reminder of the general principles of amputation, that is, to preserve the maximum length consistent with a high likelihood of primary healing, combined with ease of prosthetic fitting to provide maximum rehabilitation potential. The advantages of the transmetatarsal amputation are its excel¬ lent functional result, minimal disability, and lack of formal prosthetic requirement. It is the ideal amputation level if several toes or the great toe are involved in an ischemie or infectious process. Its disadvantage is the risk of nonhealing, necessitating
secondary amputation. The series presented today, with nearly 50% failures, suggest that this risk is very high indeed. The fundamental question, as stated by the authors and by Dr Leeds, is, how can a more acceptable rate of primary healing be achieved? The authors have stressed the importance of meticulous surgical technique. Knowing from close personal contact that they are superb clinical surgeons, I
am confident that none of their failures were technical. of clinical criteria such as the lowest palpable pulse, angiographie findings, skin temperature, reactive hyperemia (as mentioned by Dr Leeds), and other tests have not proved to be reliable predictors of healing. Recently, the measurement of ankle or forefoot blood pressures have been reported at these meetings and elsewhere to be helpful, especially when no arterial velocity signal is detectable with a Doppler probe. The authors' report indicated that they used Doppler flow assessment in a few instances. I would like to know in how many, and are they now using it routinely as an adjunct to influence their clinical decision? We have continued to use the xenon 133 washout technique to determine skin blood flow at proposed amputation levels, since the critical tissue for amputation healing and stump function is the skin. As described by Wes Moore, a xenon clearance of at least 2.7 ml/100 gm of tissue per minute correlates with virtually a 100% healing rate. We perform amputation at the most distal level where there is absence of infection and a xenon clearance of this magnitude. It is a rather simple procedure and can easily be performed in the nuclear medicine department of most hospi¬ tals. Perusal of this report has brought several other questions to
The
use
mind. First, how many of their patients had dependent rubor? We believe that dependent rubor at the level of the skin incision is an almost absolute contraindication to amputation at that level. Second, what was the morbidity in those patients who failed to heal their transmetatarsal amputations? Third, how many major lower extremity amputations were done at San Francisco General Hospital for the same indications and during the same time period? In other words, what percentage of patients in this category would they expect to be TMA candidates? Finally, why did two thirds of the failures in their series not walk, and what were their subsequent amputational levels? If TMA is not feasible, we now prefer the Syme's to the standard below-knee and have had nearly uniform success in a small series. Steven Dosick, MD, Toledo, Ohio: In keeping with this fine report, on the conservation of the patient's limb, we at the Medical College of Ohio have recently received what the prognosis is on those patients who undergo amputations. If you can keep a patient's leg so that he can walk to the bathroom, the families are often willing to keep their elderly family members. This seems to be the most important factor. Once they can no longer reach the bathroom and a bedpan must be used, they tend to go to a nursing home. Transmetatarsal amputations and bypass surgery that conserves a foot is a big factor in the ambulation. The patients who do go to the nursing home, whether it is due to the nursing home or the severity of the disease process, often die within six months. Sam Mellick, MD, Queensland, Australia: I would like to commend the presenter of this report for reminding us that, although quite rightly, below-knee amputation is the favored procedure for most distal gangrene, there is still a place for the operation described today. I think a lot of us forgot it for a while, but there is no doubt that in order to get good results with it, one has to be tremendously patient and have patients who are prepared to put up with a great deal of postoperative pain. I do not think it has been stressed yet, but there is no comparison in the postoperative course between a proximal and a distal amputation. Whether it is related to multiple bone sections as opposed to just one or two proximally, I don't know. But our patients who have undergone this procedure have had a very painful course postoperatively, and I think this has to be stressed to the patient. I wonder if I might ask the author about a couple of the technical points. He has stated that drainage is absolutely avoided. I think it should be employed. Second, he has sutured the skin. I wonder if he would comment on the use of no sutures, but just adhesive strips in a further attempt to avoid completely any damage to the anterior
flap.
Dr Lim: To answer Dr Leeds, we agree with him that control of infection is necessary to insure success. In our report, we gave complete credit to Dr McKittrick and Dr Wheelock in pioneering this procedure. To answer Dr Goldstone's questions, the use of the xenon clearance, as Dr Moore and he have utilized in defining the level of amputation, is a very good one. As more experience is gained, it would probably be a very accurate way to determine amputation levels, even at the foot level. As far as rubor is concerned, it is a contraindication in performing this amputation. In all of the patients who successfully heal their amputation, there were no failures in ambulations. In regard to the transmetatarsal amputation as compared to the total number of amputations done at our institution, it is a small number and is comparable to what Dr Leeds mentioned. As far as drainage is concerned, we have not drained any amputation done for ischemie disease. There has been no problem in terms of hematoma or fluid collection in any of these amputations. We do utilize adhesive strips in selected cases and I think it is a good atraumatic way to close the wound.
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