A Guide To Transmetatarsal Amputations In Patients With Diabetes

Start Page: 82

Continuing Education Course #143 — July 2006

I am pleased to introduce the latest article, “A Guide To Transmetatarsal Amputations In Patients With Diabetes,” in our CE series. This series, brought to you by the North American Center for Continuing Medical Education (NACCME), consists of regular CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.

Transmetatarsal amputation is a viable method for long-term limb preservation for patients with diabetes. With this in mind, Christine Salonga, DPM, and Peter Blume, DPM, offer pertinent insights in preoperative assessment, a step-by-step guide to performing the procedure and informative keys to postoperative management to help facilitate optimal outcomes.

At the end of this article, you’ll find a 10-question exam. Please mark your responses on the enclosed postcard and return it to NACCME. This course will be posted on Podiatry Today’s Web site (www.podiatrytoday.com) roughly one month after the publication date. I hope this CE series contributes to your clinical skills.

Sincerely,

Jeff A. Hall
Executive Editor
Podiatry Today

INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 83 and successfully answering the questions on pg. 90. Use the enclosed card provided to submit your answers or log on to www.podiatrytoday.com and respond via fax to (610) 560-0502.
ACCREDITATION: NACCME is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by NACCME are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Drs. Salonga and Blume have disclosed that they have no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the context of the subject of their presentation.
GRADING: Answers to the CE exam will be graded by NACCME. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam.
TARGET AUDIENCE: Podiatrists
RELEASE DATE: July 2006
EXPIRATION DATE: July 31, 2007
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• evaluate patients preoperatively to assess their potential for post-amputation healing;
• discuss when revascularization may be beneficial for patients;
• describe how neuropathy and equinus can lead to ulcerations and abnormal pressure distribution;
• review key intraoperative principles with transmetatarsal amputations;
• discuss the use of primary closure with a plantar flap; and
• discuss essential post-op considerations with transmetatarsal amputations.

Sponsored by the North American Center for Continuing Medical Education.

This X-ray shows a transmetatarsal amputation. Transmetatarsal amputations can provide long-term success for limb salvage, according to the authors.
This photo depicts an open transmetatarsal amputation.
Here is a view of a transmetatarsal amputation with a medial flap.
A Guide To Transmetatarsal Amputations In Patients With Diabetes
A Guide To Transmetatarsal Amputations In Patients With Diabetes
A Guide To Transmetatarsal Amputations In Patients With Diabetes
A Guide To Transmetatarsal Amputations In Patients With Diabetes
A Guide To Transmetatarsal Amputations In Patients With Diabetes
90
Author(s): 
By Christine Salonga, DPM, and Peter Blume, DPM

   Lower extremity limb preservation among patients with diabetes continuously challenges the foot and ankle surgeon. With a significant population afflicted by this disease, podiatric physicians often perform amputations, a complication related to diabetes.1-4 The literature shows that pedal amputations occur in 60 percent of all nontraumatic lower extremity amputations with foot related disease as the most frequent cause for hospital admission.4,5

   Transmetatarsal amputations, a common partial foot amputation, succeed with long-term effectiveness in limb salvage and function.1-3,6-19 Compared to more proximal pedal amputations, this midfoot procedure proves to be the best option in respect to healing, function, patient satisfaction and long-term results.1

   Current literature often refers to the introduction of transmetatarsal amputations by Bernard and Heute in 1855.20 However, the initial application for trench foot has expanded. McKittrick later applied the procedure to other indications and introduced the adjunctive use of antibiotic therapy as a means toward facilitating a functional, salvaged limb.9 McKittrick emphasized antibiotic therapy as an integral treatment of transmetatarsal amputations for diabetic infections.9

   Indications for a transmetatarsal amputation include forefoot ailments due to infection, neuropathy, ischemia and chronic ulcerations.3,6,8-10,12,14,16,22,23 Often, a combination of the aforementioned indications complicates the presentation.1 Due to a number of factors, conservative treatment often fails. In many instances, such as gangrene or chronic wounds, a transmetatarsal amputation remains the only viable option for pedal salvage.

   Ulcerations are not uncommon in patients with diabetes due to decreased neurovascularity and uncontrolled glucose. The continuous requirement for wound care is time-consuming, expensive and often futile due to the diminished vascularity clinicians often encounter. These chronic wounds may become worse and lead to osteomyelitis. When pathology is localized to the forefoot, removing necrotic osseous and soft tissue structures of the forefoot can provide a healing environment and a high probability of a functional limb.

Essential Keys To The Preoperative Evaluation

   The healing and success of the transmetatarsal amputation depends on many factors. Podiatric physicians must assess for common comorbidities, such as coronary artery disease, hypertension, renal disease and tobacco use, as they can affect and exacerbate the diminished health status of the diabetic population.2,6,10,12,13,16,21 Among patients with diabetes, decreased immmunocompromised health status and noncompliance issues contribute to the pathological pedal condition. Ensuring a multispecialty approach — with the aid of an internist, cardiologist and infectious disease specialist — can perioperatively optimize a patient’s medical status.

   During the initial evaluation, podiatrists should review the neurovascularity, dermatology and musculoskeletal status of the lower extremity for healing potential. There must be adequate, viable soft tissues available for coverage of the amputation site upon completion of the debridement. One should also check to see if there is decreased vascular status proximal to the forefoot.

   Indeed, sufficient vascularity is paramount for the healing of a transmetatarsal amputation.15 Angiogenesis is an important factor during the process of wound healing. Ischemia and severe distal atherosclerosis, a frequent finding in patients with diabetes, contribute to the failure of limb salvage.2,3,5,10,15,17,24-27

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Anonymoussays: August 15, 2010 at 7:07 pm

very good

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Anonymoussays: September 8, 2010 at 11:54 am

thanks for this article.it is very useful

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