vol. 3 / no.

4 Foot & Ankle Specialist 177

〈 Clinical Research 〉
Preserving Functional
Capacity as Opposed to
Tissue Preservation in
Thomas S. Roukis, DPM, PhD, FACFAS,
Niten Singh, MD, FACS, and
Charles A. Andersen, MD, FACS

the Diabetic Patient

A Single Institution Experience
Abstract: The authors performed a
retrospective review of prospectively col-
lected data of all diabetic patients who
underwent transmetatarsal amputation
(TMA) for toe gangrene or neuropathic
Forefoot varus deformity was present in ambulatory diabetic patients with
in 22 (76%) patients, and balancing multiple digital ulcerations, allowing
was performed in 17 of these patients this patient population to remain func-
(77%) with skeletal stabilization or ten- tional and avoid multiple reoperations
don transfer. Balancing was not per- and ultimately major amputation.

“
ulceration from May 2006 to June formed in the remaining
2009. Twenty-nine TMAs were per- patients as it was not
formed in diabetic patients during the necessary or not feasible. While early toe amputation in the
study period, including 24 men and 5 Sixteen patients (55%)
women with a mean ± SD age of 66.3 ± healed primarily and
diabetic patient has been shown to be
7.5 years. The indications for TMA were 5 patients (17%) devel- cost-effective in the short term, the natural
gangrene of ≥ 2 digits in 12 patients oped minor wound sep-
(41%) and neuropathic ulceration with aration that healed via history of toe amputations does not bode
underlying osteomyelitis or abscess and secondary intention. An
a concomitant dysfunctional forefoot additional 4 patients well over the long term.”
in 17 patients (59%). Of the 12 patients were able to maintain
who presented with toe gangrene, 7 functional revision pro-
(58%) underwent endovascular inter- cedures confined to the foot (1 TMA Keywords: osteomyelitis; amputation;
vention and 5 (42%) underwent open revision, 3 Chopart amputations). limb salvage; foot surgery techniques;
vascular bypass. Equinus contracture Three patients (10%) required below- tendon imbalance
was present in 27 patients (93%), and knee amputation, and there were 2

26 (96%) of these patients underwent
tendo-Achilles lengthening or gastroc-
nemius recession. Correction of equi-
nus contracture was not performed in
1 patient as it was deemed not feasible.
A
deaths (7%) during the time period. mputation is largely considered an
Functional amputation confined to the undesired endpoint when treat-
foot was achieved in 86% of ambula- ing limb-threatening conditions of
tory diabetic patients. These results sup- the lower extremity. Although all reason-
port a more aggressive initial approach able attempts to preserve a patient’s foot

DOI: 10.1177/1938640010374217. From Madigan Army Medical Center, Tacoma, Washington. The opinions or assertions contained herein are the private view of
the authors and are not to be construed as official or reflecting the views of the Department of the Army or the Department of Defense. Address correspondence to
Charles A. Andersen, MD, FACS, Chief, Vascular Surgery Service, Department of Surgery, Madigan Army Medical Center, 9040-A Fitzsimmons Drive, MCHJ-SV, Tacoma, WA
98431; e-mail: charles.a.andersen@us.army.mil.
For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright © 2010 The Author(s)
178 Foot & Ankle Specialist August 2010

should be considered, the functionality

of the limb and likelihood of recurrent Figure 1.
ulceration or infection must be assessed.1 Example of a patient who underwent multiple partial toe and metatarsal amputations
While early toe amputation in the dia- over a 10-year period. This patient required weekly follow-up during this entire time
betic patient has been shown to be cost- frame until successfully treated with bilateral transmetatarsal amputations with
effective in the short term,2,3 the natural tendon balancing. He is now seen on a yearly basis for foot checks and fabrication of
history of toe amputations does not bode extradepth diabetic shoe gear and accommodative insoles.
well over the long term.4-13
Toe ulcerations have been shown to
be a significant causative factor in major
lower-limb amputations in more than
70% of patients in some series.14-16 If the
forefoot or toe wound does heal, the
development of gait abnormalities and
adjacent toe and forefoot wounds leading
to more proximal partial foot or lower-
limb amputation is the rule rather than
the exception.9-14
Amputating a toe or metatarsal ray in
isolation rarely results in a functional
foot and leaves a deformity that is diffi-
cult if not impossible to protect from fur-
ther ulceration or progressive deformity
(Figure 1). The result is repeated ulcer-
ation about the forefoot and progres-
sive amputations of the residual toes and
metatarsals (ie, “whittling disease”), often
leaving an unstable, heavily scarred, and
deformed residual forefoot. Subsequent
partial foot amputation is made more
difficult by the presence of dense and
avascular scar tissue around the distal
forefoot from previous toe or metatarsal from May 2006 to June 2009. All patients Patients diagnosed with neuropathic
ray amputations.17 diagnosed with gangrene of ≥2 digits or ulceration and underlying osteomyeli-
In some cases, a well-balanced primary neuropathic ulceration with underlying tis or abscess were treated with emergent
transmetatarsal amputation (TMA) will osteomyelitis or abscess were collectively surgical incision and drainage of infected
provide the patient with a more dura- treated by the Vascular/Endovascular tissues, including toe and/or ray ampu-
ble extremity that will allow the patient Surgery and Limb Preservation Services tation when necessary, administration of
to better maintain his or her indepen- to afford a multidisciplinary approach to broad-spectrum systemic antibiotic ther-
dence than multiple toe-salvage proce- patient care. apy directed by an infectious disease
dures.1,17-20 We examined our experience Patients diagnosed with gangrene were specialist, optimization of medical comor-
with a multidisciplinary approach to limb treated with inpatient optimization of bidities, and noninvasive vascular stud-
preservation in which a more aggres- medical comorbidities and further eval- ies. Repeated irrigation and débridement
sive approach has evolved in ambula- uation with noninvasive vascular stud- and/or vascular intervention were per-
tory patients with digital ulcerations using ies. Angiography was performed based formed as necessary in order to perform
TMA and balancing as opposed to iso- on physical examination and noninva- TMA with balancing.
lated digital amputation. sive study results with the intention to TMA was performed with preservation
treat amenable vascular occlusive lesions. of the intrinsic pedal musculature adjacent
Open peripheral vascular bypass was to the metatarsals with special attention
Patients and Methods performed when an adequate distal ves- paid to preserving the communicating
We performed a retrospective review of sel was identified and if the patient did branch connecting the dorsalis pedis and
our prospectively collected database of not have factors precluding a bypass. lateral plantar arteries. All attempts were
all diabetic patients who underwent TMA TMA with balancing was performed once made to preserve the weight-bearing
for toe gangrene or neuropathic ulcer- optimization of perfusion was deemed to surface of the plantar forefoot to provide
ation at Madigan Army Medical Center have occurred. the most durable tissue for coverage;
vol. 3 / no. 4 Foot & Ankle Specialist 179

studies or arteriography as necessary. Of

Figure 2. the 12 patients who presented with toe
(A) Preoperative view of a forefoot inversion contracture following resection to gangrene, 7 (58%) underwent endovas-
several deformed and ulcerated central toes. (B) Immediate postoperative view cular intervention and 5 (42%) under-
following completion of percutaneous tendo-Achilles lengthening, transmetatarsal went open vascular bypass. None of the
amputation, and peroneus brevis to peroneus longus tendon transfer as described. patients who presented with neuropathic
Note the correction of the forefoot inversion deformity when compared with (A). ulceration required vascular intervention;
(C) Clinical photograph of the same patient 12 months postoperatively however, 4 patients underwent diagnos-
demonstrating maintained reduction of the forefoot varus deformity and lack of tic arteriography of the involved limb.
ulceration or progressive deformity. An equinus contracture of the Achilles
tendon was present in 27 patients (93%),
and 26 (96%) of these patients were
treated at the time of TMA. Percutaneous
tendo-Achilles lengthening was used in
16 patients (59%) and gastrocnemius
recession in 10 patients (41%). Adequate
reduction of the equinus contracture
was achieved in all cases. Forefoot
varus deformity was present in 22 (76%)
patients, and balancing was performed
at the time of TMA in 17 (77%) of these
patients. Skeletal stabilization with intra-
medullary screw fixation was employed
in 5 patients (29%), tendon transfer with
however, the location and size of the and additional medical or surgical man- a peroneus brevis to peroneus longus
defect dictated the final tissues employed agement performed. transfer in 7 patients (42%), and transfer
to achieve primary closure. When neces- Statistical analysis consisted of calcu- of the flexor hallucis longus to the first
sary, equinus contracture was corrected lation of a Kaplan-Meier survival curve metatarsal and extensor digitorum lon-
with percutaneous tendo Achilles length- determining the probability of maintain- gus tendon slips to the third and fourth
ening in the vascularly compromised ing functional amputation at the foot metatarsals in 5 patients (29%). Forefoot
patient and open gastrocnemius recession level for patients who underwent TMA balancing was not performed in 12
in the neuropathic ulceration patient, for for gangrene on ≥2 toes (group 1) or patients (41%), as it was not necessary in
the reasons discussed later. If varus pos- neuropathic ulceration with underlying 7 patients (58%) and not feasible due to
ture of the residual forefoot was present, osteomyelitis or abscess (group 2) using limited regional perfusion in 5 patients
this was corrected with intramedullary MedCalc (www.medcalc.be). (42%; Figure 3).
screw placement or transfer of the flexor Sixteen patients (55%) healed primar-
hallucis longus tendon to the residual first ily without complication, and 5 patients
metatarsal and extensor digitorum lon- Results (17%) developed minor wound sepa-
gus to the residual fourth metatarsal in Twenty-nine TMAs were performed in ration that healed via secondary inten-
the vascularly compromised patient and diabetic patients during the study period, tion. The remaining 8 patients (28%)
peroneus brevis to peroneus longus ten- including 24 men and 5 women, with a developed major complications includ-
don transfer in the neuropathic ulceration mean ± SD age of 66.3 ± 7.5 years (range, ing ulceration of the plantar-lateral TMA
patient (Figure 2). 50-84 years). The left foot was involved stump in 3 patients (38%) who did not
All patients remained hospitalized until 16 times and the right 13 times. The indi- undergo forefoot balancing due to lim-
their first postoperative dressing change, cations for TMA were gangrene of ≥2 dig- ited regional perfusion, with 1 patient
at which point physical therapy was con- its in 12 patients (41%) and neuropathic undergo below-the-knee amputation
sulted to initiate bed-to-wheelchair and ulceration with underlying osteomyeli- (BKA), 1 patient undergoing Chopart
bedside commode transfer training with tis or abscess and a concomitant dysfunc- amputation, and 1 patient dying of
strict non–weight bearing to the opera- tional forefoot in 17 patients (59%). The cardiac-related causes prior to healing
tive foot. Most patients required skilled mean ± SD follow-up for the patients (Figure 4). A total of 5 patients (17%)
nursing facility placement until able to with gangrene of ≥2 digits was 7.9 ± 4.3 developed ischemic necrosis of the plan-
safely perform these activities such that months and 9.7 ± 6.7 months for the tar TMA flap, with 2 patients undergoing
they could return to their own homes. All patients with neuropathic ulceration. Chopart amputation, 2 patients undergo-
patients were followed weekly until fully All patients underwent vascular ing BKA, and 1 patient undergoing TMA
healed or failure to heal was declared examination to include noninvasive revision and coverage with a split-thickness
180 Foot & Ankle Specialist August 2010

ulcerations, underwent staged bilat-

Figure 3. eral above-knee amputations, and died
Transmetatarsal amputation deformity correction. of cardiac-related causes after heal-
ing his higher level amputations. A total
of 3 patients (10%) initially presenting
with gangrene of ≥2 digits required BKA.
There were 2 deaths (7%) during the time
period in patients initially presenting with
gangrene of ≥2 digits. The Kaplan-Meier
probability of maintaining a functional
amputation at the foot level revealed a
significant difference (P = .03) between
those patients initially presenting with
gangrene of ≥2 digits having decreased
likelihood compared with those pre-
senting with neuropathic ulceration and
osteomyelitis or abscess (Figure 5).

Discussion
The ultimate goal of forefoot salvage
TMA indicates transmetatarsal amputation; IM, intramedullary; PB, peroneus brevis tendon; PL,
should be to create a stable, plantigrade,
peroneus longus tendon; FHL, flexor hallucius longus tendon; EDL, extensor digitorum longus tendon. shoeable/braceable, functional foot capa-
ble of withstanding repeated ambulation.1
When approaching toe ulcerations with
Figure 4.
underlying osteomyelitis or gangrene,
the natural tendency is to minimize the
Patient outcomes following transmetatarsal amputation. extent of amputation to the involved toe
or adjacent ray. However, after review
of the literature pertaining to isolated
toe amputation, it is clear that ampu-
tating a toe or metatarsal ray in isola-
tion rarely results in a functional foot and
leaves a deformity that is difficult if not
impossible to protect from further ulcer-
ation or progressive deformity. Isakov
et al6 followed 212 diabetic patients and
found that 62.2% of the lesions respon-
sible for lower-leg amputations were
located on the toes. Nehler et al7 fol-
lowed 92 diabetic patients with 97 toe
wounds treated with primary toe ampu-
tations for a mean of 21 months. Only 34
of 97 (34%) wounds completely healed,
with the remainder undergoing either
BKA indicates below-knee amputation; OM, osteomyelitis; TMA; transmetatarsal amputation.
major lower-limb amputation or remain-
ing unhealed at the final follow-up exam-
ination.7 Other series have revealed major
amputation rates following initial toe
skin graft (STSG). Of the 13 patients who to achieve functional amputation con- amputation of 49% to 75% during follow-
did not heal their TMA, 4 (31%) were fined to the foot (Figure 4). All of these up periods of 10 months to 3.5 years.9-12
able to maintain functional revision pro- patients have remained ambulatory in Despite the short follow-up of our patient
cedures confined to the foot (1 TMA revi- assistive brace/shoe gear. population, our data demonstrate that
sion, 3 Chopart amputations). Therefore, One patient who healed his TMA pri- ambulatory patients can regain functional
a total of 25 (86%) patients were able marily developed bilateral posterior heel ambulation with protective brace/shoe
vol. 3 / no. 4
Figure 5.
Probability of maintaining a functional amputation confined to the foot.
Months
gear therapy following early transmeta-
tarsal amputation with soft-tissue and/or
osseous balancing of pedal deformities if
present and feasible to treat. These good
results are especially true of patients with
adequate vascular perfusion (ie, nonisch-
emic etiology/neuropathic ulceration).
Furthermore, we believe that the natu-
ral history of isolated toe amputations for
treatment of localized gangrene or neuro-
pathic ulceration with underlying abscess
of osteomyelitis is not encouraging and
should be reserved for patients with lim-
ited mobility or life expectancy. In addi-
tion, we continue to believe, however,
that nonambulatory patients with short
life expectancy should undergo either
isolated toe amputation or higher-level
amputation as the primary procedure.
TMAs have been employed with vary-
ing degrees of success since first being
formally evaluated in the early part of
the 20th century.21-39 It is interesting to
note that while the surgical approach
has evolved from an open amputation
with protracted periods of bed rest and
wound packing followed by skin graft-
ing to a single-stage procedure with pri-
mary closure of a thick plantar flap, the
overall success rate has not improved.
Specifically, failure rates for all-cause
TMAs requiring higher-level amputation
have been reported from 17% to 56%.21-41
Causes of failure have included persistent
host factors for delayed healing (ie, pro-
tracted hyperglycemia, malnutrition, etc),
progressive infection, nonreconstructa-
ble occlusive vascular disease, patient
noncompliance during the postopera-
tive period or with long-term shoe gear
use, and structural or dynamic imbal-
ance of the residual foot. Because of loss
of the insertions of some of the extrin-
sic pedal musculature and the loss of
the metatarsal head weight-bearing sur-
face, TMA is known to be associated with
imbalance of the residual foot, and this
can lead to complications related to cuta-
neous compromise, as well as difficul-
ties with bracing and shoe fit.40-43 The
concept of balancing TMAs through var-
ious soft-tissue tendon transfers or osse-
ous realignment such that the ankle has
full dorsiflexion (ie, no equinus) and the
forefoot contacts the weight-bearing sur-
face as a collective unit (ie, no varus)
has recently become popularized.41-46
It stands to reason that after address-
ing reversible causes of failure to heal
mentioned above, if the residual foot
following TMA is balanced, then func-
tion should be improved and the likeli-
hood of recurrent ulceration should be
reduced. The authors believe this is dem-
onstrated by our results since none of the
patients who underwent balancing have
Foot & Ankle Specialist 181
ulcerated or required revision surgery,
whereas 3 patients with varus forefoot
deformity who could not undergo bal-
ancing due to limited regional perfusion
readily ulcerated at the plantar-lateral
residual forefoot and required higher-
level amputation. In addition, even when
complications arose, we were able to
achieve successful functional limb preser-
vation with a TMA revision and STSG or
Chopart amputation. Close
follow-up during the postoperative
period and emphasis on daily patient
pedal hygiene and the use of protective
shoe gear cannot be overemphasized.1,47,48
Weaknesses of our study involve the
retrospective means of reviewing the
patient data collected and the inherent
inaccuracies associated with this form of
data review. However, as the data itself
were collected in prospective fashion and
we function in a closed medical system,
we were able to review consistent data
and follow patients without attrition. In
addition, we had a small patient popu-
lation that is likely underpowered, espe-
cially when considering the small subset
of patients within each group that under-
went TMA. However, each patient had
diabetes, which limits patient selection
bias, and all of the TMAs were performed
by one of us (T.S.R.) using a consistent
surgical technique and postoperative
follow-up protocol, which limits variabil-
ity in patient care factors. Unfortunately,
no formal joint range-of-motion measure-
ments or gait analysis was consistently
performed preoperatively or postoper-
atively, which could aid in determining
the elements of balancing that are neces-
sary for proper function. However, clini-
cal examination of the patients included
clearly demonstrates resolution of equi-
nus contracture and varus deformity fol-
lowing balancing as described here, as
well as maintenance of a stable, durable,
and functional residual foot capable of
ambulation within protective shoe gear.
Finally, our data do not answer the
question about the marked difference
in the ability to achieve a healed TMA
or partial foot amputation between the
gangrenous toes with ischemic disease
and neuropathic ulcerations without isch-
emic disease. Further data are necessary,
182 Foot & Ankle Specialist
preferably involving prospective methods
and an appropriate number needed to
treat to obtain statistical significance.
Conclusions
The natural history of isolated toe
amputations for treatment of localized
gangrene or neuropathic ulceration with
underlying abscess of osteomyelitis is
not encouraging and should be reserved
for patients with limited mobility or life
expectancy. Our results support a more
aggressive initial approach in ambula-
tory diabetic patients with multiple digital
ulcerations, allowing this patient popula-
tion to remain functional and avoid mul-
tiple operations and ultimately major
amputation. Close follow-up and daily
patient use of protective shoe gear can-
not be overemphasized. As history has
shown, patients with a short life expec-
tancy should undergo either isolated toe
amputation or higher-level amputation as
the primary procedure.
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