This study is a retrospective review of transmetatarsal amputation (TMA) outcomes in patients with diabetes and non-healing ulcers of the forefoot. All were treated by single stage TMA and insertion of antibiotic beads in the surgical wound. Healing time was approximately eighteen weeks with a failure rate (subsequent BKA) of 25%. This is in contrast to literature values of healing times (not isolated to diabetics) of twenty-eight weeks and BKA rates of 34–40%. The decreased morbidity associated with our surgical procedure may address the costly management of diabetic foot ulcers (presently estimated to be $600 million per year). The purpose of this study was to review the outcome of transmetatarsal amputation (TMA) in diabetic patients as a single stage procedure using antibiotic pellets in the wound. We report faster healing times and a decreased rate of subsequent below-knee amputation (BKA) when compared with related studies in the literature. 1) Our procedure may decrease morbidity in a problem (diabetic foot ulcer management) costing approximately $600 million per year. 2) This study uniquely addresses TMA in diabetics. Mean healing time was eighteen weeks (range six to forty weeks). Patients with intact foot pulses or reconstructed vasculature had a mean recovery time of 12.5 weeks. Healing times for unreconstructable vasculature or documented deep infection were thirty weeks and twenty weeks respectively. The overall failure rate (BKA) was 25%. Neither vascular status nor the presence of deep infection predicted subsequent BKA. Retrospective review of patient charts. Forty consecutive diabetic patients (mean age 58.3 yrs, range 40–77) with foot ulcers of >
twelve weeks duration had TMA performed at a tertiary care center by one of three surgeons. Data tabulated included demographics, diabetes profiling, vascular interventions and follow-up parameters. Diabetic foot ulcer morbidity is a significant cost burden to health care; despite this, salvage procedures for this problem are not well studied. Previous papers (not isolated to diabetics) report TMA healing times of twenty-eight weeks and subsequent BKA rates of 34–40%. Refinements of the TMA technique in diabetics may decrease early and late morbidity and thus address this costly problem.
The cost effective management of diabetic foot infections is a challenge to the Canadian health system. The objective of this study was to predict preoperatively diabetic foot patients who will fail a transmetatarsal amputation (TMA) and end in a costly and disabling below knee amputation (BKA) and hence perform a primary BKA in select patients. Twenty-one patients failing TMA and revised to BKA within the first year were compared with a matched cohort of twenty-one successful TMA’s. The factors that were selected for comparison were: age at amputation, sex, smoking, type of DM, use of osetoset, presence of charcot fractures, previous contralateral surgery, previous debridement before TMA, debridement after TMA, dialysis, duration of ulcer prior to TMA, hemoglobin level at time of TMA, HbA1C, presence of heel ulcer, prior ipsilateral toe amputation, pulse status prior to TMA, vascular reconstruction and presence of unre-constructable vascular problem. Chi-square was done for group data, and ANOVA for numeric data. Long-term control of blood glucose level (HbA1C) was found to be significant in predicting the success of TMA. Need of debridement after TMA was found to be a significant predictor of failure of TMA. There was a trend towards duration of ulcer prior to TMA and smoking being significant. All other variables, including vascular status or renal failure were not significantly different between the two groups. As we have previously achieved a 75% success rate with TMAs in diabetics, we recommend a TMA as the first procedure in all diabetics with major forefoot infection or ulceration instead of a BKA. Obtaining good diabetic control in patients at risk for or requiring amputation for foot infection may prevent the TMA from failing and the subsequent need for BKA.
