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Transmetatarsal Amputation: A Case Series and Review of the Literature

DOI: 10.1155/2012/797218

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Abstract:

Foot ulceration is a major cause of morbidity amongst patients with diabetes. In severe cases of ulceration, osteomyelitis and amputation can ensue. A distinct lack of agreement exists on the most appropriate level of amputation in cases of severe foot ulceration/infection to provide predictable healing rates. This paper provides an overview of the transmetatarsal amputation (TMA) as a limb salvage procedure and is written with the perspective and experiences of the Department of Podiatric Surgery at West Middlesex University Hospital (WMUH). We have reflected on the cases of 11 patients (12?feet) and have found the TMA to be an effective procedure in the management of cases of severe forefoot ulceration and infection. 1. Introduction In recent times, increased attention has been placed on the alarming increase in the incidence of diabetes. Diabetic foot ulcers occur in up to 15% of diabetic patients [1], and amputation rates amongst this population have been documented as 11% [2]. In particular cases of severe foot infection, amputation should not necessarily be looked upon as failure of care, but rather the most appropriate intervention for preventing more proximal spread and persistent hospital attendance. Aggressive management of severe foot infection/ulceration can reduce the risk of proximal amputation. 2. Transmetatarsal Amputation A proportion of the diabetic community experience serious and debilitating complications associated with their feet, with a 12–25% increased risk of developing foot ulceration [3]. Development of diabetic foot ulceration is often a multifactorial process; however, the presence of influences such as neuropathy and peripheral vascular disease is recognised as significant contributing factor. The neuroischaemic ulceration accounts for 90% of those encountered in the diabetic population [4], and approximately half of diabetic foot wounds develop an infection, the majority involving only soft tissue [5]. In circumstances where soft tissue infection is severe or where underlying bone is infected, amputation may be considered an appropriate line of treatment. Mills et al. [6] recognised that infection and gangrene due to microvascular disease were two major factors that resulted in failure of wound healing, resulting in amputation. At WMUH, a treatment pathway has been developed for patients with severe foot ulceration/infection who have been deemed suitable candidates for undergoing TMA (see Assessment and Treatment below). Patients are urgently admitted into the hospital and are assessed by the medical and surgical teams,

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