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Background:. Transmetatarsal amputation (TMA) is performed in patients with nonhealing wounds of the forefoot. Compared with below-knee amputations, healing after TMA is less reliable, and often leads to subsequent higher-level amputation. The aim of this study was to evaluate the functional and patient-reported outcomes of TMA.
Methods:. A retrosp...
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Context 1
... 3 summarizes the postoperative complications and long-term outcomes among TMA success and higher-level amputee groups. On multivariate regression analysis, postoperative infection (odds ratio: 4.39, P = 0.005) was an independent predictor of TMA failure and subsequent proximal amputation (Table 4). ...Citations
Midfoot amputations provide an opportunity for limb salvage through preservation of a weight-bearing limb. However, the longevity of midfoot amputations is threatened by restrictions in surface area and risks of skin breakdown. To better inform decisions surrounding the level of amputation, we sought to compare outcomes of high-risk individuals who underwent Lisfranc or Chopart amputations. A single-center retrospective cohort study was performed from November 2013 to September 2022 of adult patients who underwent Lisfranc or Chopart amputations. Patients were stratified into cohorts based on the amputation type. Outcomes included postoperative rates of re-amputation, functional status, mortality and patient-reported outcome measures in the form of Lower Extremity Functional Scale scores. Sixty-six patients were identified; of which, 45 underwent Lisfranc amputation, and 21 underwent Chopart amputation. Median Charlson Comorbidity Index was 7, signifying a substantial comorbidity burden. By median follow-up of 14 (Interquartile range: 28) months, 31 patients (36%) progressed to higher-level amputation, and most patients were ambulatory (n=38, 58%). Overall rates of re-amputation, ambulatory status, and mortality were comparable between groups. Re-amputation to another midfoot amputation was more common among the Lisfranc cohort (n=16, 36% versus n=1, 5%), whereas re-amputation to BKA was more prevalent among the Chopart cohort (Chopart: n=7, 33% versus Lisfranc: n=7, 16%; p=0.011). Average Lower Extremity Functional Scale scores were similar between groups and corresponded to a maximal function of 48%. Lisfranc and Chopart amputations have the potential to be efficacious limb salvage options in high-risk patient populations in conjunction with intraoperative biomechanical optimization and optimal preoperative patient selection.
Background
Transmetatarsal amputation (TMA) allows for maintenance of ambulatory function in patients with significant forefoot tissue loss. Effective revascularization is key to optimizing limb salvage in patients with chronic limb threatening ischemia (CLTI). We hypothesize that CLTI patients requiring TMA have better healing and functional outcomes with open bypass (OPEN) compared with endovascular (ENDO) revascularization.
Methods
Consecutive TMAs performed at three affiliated centers between 2008 and 2020 were retrospectively reviewed. Baseline characteristics including WIfI stage, non-invasive vascular studies, healing, and ambulatory outcomes were collected. Catheter-based angiographic images were evaluated using the GLASS system. Primary outcomes were TMA healing and community ambulation, with secondary outcomes of TMA healed at end of study, any ambulatory function postoperatively, major amputation, and mortality. Descriptive statistics, univariate, multivariable, and Kaplan-Meier analyses were performed.
Results
346 TMAs were performed in 318 patients, 209 of whom had peripheral artery disease (PAD). Median follow up was 2. 5 years. Patients with PAD had significantly lower rates of healing compared to those without (64% vs. 77%, p=0.007). Revascularization was performed in 185 limbs with 102 treated ENDO and 83 OPEN. Patients who underwent ENDO were significantly less likely to heal their TMA at any time (55% vs. 76%, p=0.003) and less likely to remain healed at the end of study (49% vs 66%, p=0.02). Patients with GLASS stage 3 anatomy were significantly more likely to heal with OPEN (75% vs 45%, p=0.003). Long term ambulation data was available for 72% of revascularized patients. ENDO was associated with lower likelihood of community ambulation after TMA (34% vs 57%, p=0.002). In multivariable analysis, OPEN was significantly associated with TMA healing (OR 2.8, p=0.007) and ambulation (OR 2.9, p=0.001).
Conclusion
In patients with CLTI and significant tissue loss requiring TMA, initial OPEN approach to revascularization was associated with improved healing and higher rates of ambulation than ENDO. The metabolic requirement to heal a TMA in CLTI patients may be better met by open revascularization.
