Transmetatarsal Amputation

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Transmetatarsal amputation (TMA) is a relatively common operation that is performed to safeguard limb viability.^[1]Originally used for trench foot, TMA now has widespread uses in both orthopedic and vascular surgery because it treats patients with infection of the forefoot, necrosis, gangrene, and diabetic neuropathy, who commonly develop ulcerations. Bernard and Heute first described TMA in 1855, but it was McKittrick et al in 1949 who used it as an alternative to higher amputations in patients with the above signs and symptoms.^[2]

The aims of TMA are as follows:

Candidates for TMA are chosen on the basis of limited irremediable tissue loss, typically occurring as a result of infection or ischemic changes in the foot.^[3]The essential factor that must be taken into consideration is the individual patient’s vascular sufficiency, which directly affects healing after amputation.

The clinical indications for TMA are as follows:

Contraindications for TMA include the following:

The metatarsal bones are numbered 1 through 5, from medial to lateral. Each metatarsal has a head, neck, shaft, and base. The metatarsal bones are roughly cylindrical in form. The body tapers gradually from the proximal to distal end. They are curved in the long axis and present a concave plantar surface and a convex dorsal surface.

The base at the proximal end is wedge-shaped, articulating proximally with the tarsal bones and by its sides with the contiguous metatarsal bones; its dorsal and plantar surfaces are rough for the attachment of ligaments.

The head at the distal end presents a convex articular surface, oblong from above downward, and extending farther backward plantar than dorsal. Its sides are flattened, and on each is a depression, surmounted by a tubercle, for ligamentous attachment. Its plantar surface is grooved anteroposteriorly and marked on either side by an articular eminence continuous with the terminal articular surface.

For more information about the relevant anatomy, see Foot Bone Anatomy.

Statistics from the 1990s indicated that approximately 10,000 TMAs were performed in the United States, compared with 32,000 above-knee amputations (AKAs) and 22,000 below-knee amputations (BKAs).^[5]TMA, when feasible, is the logical preference because it is the only amputation procedure that allows for potential weightbearing.

Rehabilitation from more proximal amputations for peripheral vascular disease (eg, AKAs and BKAs) is seldom a success. Only 5% of amputees mobilize outside the confines of their home with a prosthesis, and most of those who do will become wheelchair-dependent within 5 years. In theory, TMAs should yield better mobilization percentages. In a study of 4965 nursing-home residents who underwent amputation, patients who underwent BKA (n = 1596) or AKA (n = 2879) recovered more slowly than those who underwent TMA (n = 490) and did not return to baseline function by 6 months.^[6]

A weightbearing residuum is not the only advantage of TMA: Studies have shown that it is associated with a lower mortality than either AKA or BKA.^{[7, 8]}In one study, TMA had a 30-day postoperative mortality of 3%,^[9]whereas in another study, BKA had a 30-day postoperative mortality of 6.3% and AKA had a 30-day postoperative mortality of 13.3%.^[10]

In a study comparing digital amputation (n = 77) with transmetatarsal amputation (n = 70) in 147 diabetic patients with gangrenous toes, Elsherif et al found that transmetatarsal amputation offered better outcomes, with a lower reintervention rate (15.7% vs 29.9%), a shorter median hospital stay (17 days vs 20 days), fewer theater trips, and a longer time without toxicity (346 days vs 315 days).^[11]However, the differences did not reach statistical significance.

Tan et al retrospectively evaluated outcomes after TMA for peripheral arterial disease (PAD) limb salvage in 147 Asian patients and undertook to identify risk factors associated with TMA failure.^[12]They reported a success rate of 63% for PAD limb salvage TMA and noted that diabetes was an independent predictor of TMA failure. Patients in whom TMA failed were found to be at increased risk for nosocomial infections and 30-day readmissions.

Adams et al assessed 3-year mortality and morbidity in 375 patients who underwent nontraumatic TMA, examining variations in TMA complication rates according to sex, age, race, and comorbid conditions.^[13]After a nontraumatic TMA, 136 (36.3%) patients died within 3 years, 138 (36.8%) required a more proximal limb amputation, and 83 (22.1%) healed without complications. Patients with nonpalpable pedal pulses were three times as likely to require a proximal limb amputation, almost twice as likely to die within 3 years, and more than twice as likely not to heal after the TMA. Patients with end-stage renal disease were three times as likely to die within 3 years.

Wheeless CR III. Transmetatarsal amputations. Wheeless Online. Available at http://www.wheelessonline.com/ortho/transmetatarsal_amputation. May 14, 2012; Accessed: September 12, 2018.

McKittrick LS, McKittrick JB, Risley TS. Transmetatarsal Amputation for Infection or Gangrene in Patients with Diabetes Mellitus. Ann Surg. 1949 Oct. 130 (4):826-40. [Medline]. [Full Text].

Anthony T, Roberts J, Modrall JG, Huerta S, Asolati M, Neufeld J, et al. Transmetatarsal amputation: assessment of current selection criteria. Am J Surg. 2006 Nov. 192 (5):e8-11. [Medline].

Ammendola M, Sacco R, Butrico L, Sammarco G, de Franciscis S, Serra R. The care of transmetatarsal amputation in diabetic foot gangrene. Int Wound J. 2017 Feb. 14 (1):9-15. [Medline].

Mueller MJ, Sinacore DR. Rehabilitation factors following transmetatarsal amputation. Phys Ther. 1994 Nov. 74 (11):1027-33. [Medline].

Vogel TR, Petroski GF, Kruse RL. Impact of amputation level and comorbidities on functional status of nursing home residents after lower extremity amputation. J Vasc Surg. 2014 May. 59 (5):1323-30.e1. [Medline]. [Full Text].

Pollard J, Hamilton GA, Rush SM, Ford LA. Mortality and morbidity after transmetatarsal amputation: retrospective review of 101 cases. J Foot Ankle Surg. 2006 Mar-Apr. 45 (2):91-7. [Medline].

Thomas SR, Perkins JM, Magee TR, Galland RB. Transmetatarsal amputation: an 8-year experience. Ann R Coll Surg Engl. 2001 May. 83 (3):164-6. [Medline]. [Full Text].

Geroulakos G, May AR. Transmetatarsal amputation in patients with peripheral vascular disease. Eur J Vasc Surg. 1991 Dec. 5 (6):655-8. [Medline].

Feinglass J, Pearce WH, Martin GJ, Gibbs J, Cowper D, Sorensen M, et al. Postoperative and late survival outcomes after major amputation: findings from the Department of Veterans Affairs National Surgical Quality Improvement Program. Surgery. 2001 Jul. 130 (1):21-9. [Medline].

Elsherif M, Tawfick W, Canning P, Hynes N, Sultan S. Quality of time spent without symptoms of disease or toxicity of treatment for transmetatarsal amputation versus digital amputation in diabetic patients with digital gangrene. Vascular. 2018 Apr. 26 (2):142-150. [Medline].

Tan MNA, Lo ZJ, Lee SH, Teo RM, Tan WLG, Chandrasekar S. Review of Transmetatarsal Amputations in the Management of Peripheral Arterial Disease in an Asian Population. Ann Vasc Dis. 2018 Jun 25. 11 (2):210-216. [Medline]. [Full Text].

Adams BE, Edlinger JP, Ritterman Weintraub ML, Pollard JD. Three-Year Morbidity and Mortality Rates After Nontraumatic Transmetatarsal Amputation. J Foot Ankle Surg. 2018 Sep – Oct. 57 (5):967-971. [Medline].

Boffeli TJ, Waverly BJ. Medial and Lateral Plantar Artery Angiosome Rotational Flaps for Transmetatarsal and Lisfranc Amputation in Patients With Compromised Plantar Tissue. J Foot Ankle Surg. 2016 Mar-Apr. 55 (2):351-61. [Medline].

Sage R, Pinzur MS, Cronin R, Preuss HF, Osterman H. Complications following midfoot amputation in neuropathic and dysvascular feet. J Am Podiatr Med Assoc. 1989 Jun. 79 (6):277-80. [Medline].

Boffeli TJ, Pfannenstein RR, Thompson JC. Radiation therapy for recurrent heterotopic ossification prophylaxis after partial metatarsal amputation. J Foot Ankle Surg. 2015 May-Jun. 54 (3):345-9. [Medline].

Boffeli TJ, Thompson JC, Waverly BJ, Pfannenstein RR, Mahoney KJ. Incidence and Clinical Significance of Heterotopic Ossification After Partial Ray Resection. J Foot Ankle Surg. 2016 Jul-Aug. 55 (4):714-9. [Medline].

Palaniappan Lakshmanan, MBBS, MS, AFRCS, FRCS(Tr&Orth) Consultant Spinal Surgeon, Department of Trauma and Orthopaedics, Sunderland Royal Hospital, UK

Palaniappan Lakshmanan, MBBS, MS, AFRCS, FRCS(Tr&Orth) is a member of the following medical societies: British Orthopaedic Association, AOSpine