Desmond P. Bell, Jr., DPM
CWS, FACCWS
“Save A Leg, Save A Life”™
Foundation
Wound Care on Wheels, LLC
Jacksonville, Florida

“How to Perform the Ideal
Toe and
Transmetatarsal Amputation”
Converting Less….
into More

Survival Rates After Amputation:
“Our Daily Motivation”
 After 1 major lower-extremity amputation
– 3-year survival rate is 50%
– 5-year survival rate is 40%
 Contralateral amputation
– 42% of patients within 1 to 3 years after
first amputation
– 56% of patients within 3 to 5 years after
first amputation
American Diabetes Association. Diabetes 1996 Vital Statistics.
American Diabetes Association. Diabetes 1996 Vital Statistics.

“Setting Up for Success”
 Consider:
Vascular Status
Infection
Extent of Infection

“Setting Up for Success”
Consider:
Level, Degree and Quality
of Viable Tissue
Ambulatory Status of Patient
Acute vs. Chronic
Progression
Short Term Solution vs. Long
Term Function

Digital Amputation
 Evaluate extent of
viable tissue when
planning incision
 Attempt to preserve as
much viable soft tissue
as possible

Digital Amputation
Incision Guide

Digital Amputation
 Carry incision to bone
 May be easier to disarticulate vs. resect portion of
phalanx (situation dictates degree of bony
resection)
 Consider partial toe resection that will create
buttress to help reduce shifting of digits

Digital Amputation

Digital Amputation
Hallux

Long Term Sequelae of
Digital Amputation
 Amputation of lesser digits generally results in
minimal disturbance in gait
 Amputation of hallux results in an apropulsive gait
 Extensor and flexors of hallux are resected,
results in hammertoe contractures or adducting of
digits to “fill in” deficit created by amputated digit
 Increased metatarsal pressures, especially at
submet 2 after hallux amputation

The Less Than Ideal Digital Amputation
 Although the
circumstances may
vary, surgical
principles remain
consistent when
performing digital
amputations to
respective levels

The Less Than Ideal Digital Amputation
Gas in tissue necessitating wider resection

The Ideal Result
Both cases utilized NPWT, living skin substitutes
and Offloading with Soft Total Contact Cast

Any Similarities to the Patients on the Previous
Slides, Whether Real or Implied is Purely
Coincidental…..

Transmetatarsal Amputation
 TMA Provides:
Better option than Below
Knee Amputation
Creates a Better
Functioning Foot when
greater than 2 toes
have previously been
amputated
*DO NOT LEAVE A FOOT
WITH 1 or 2 TOES!

Poorly Functioning Feet
Remnants of toes do not provide “stability”, only greater imbalance.
Increased focal pressure at stump sites may cause recurrent breakdown!

Transmetatarsal Amputation
Technique
 Carry incision directly to bone
 Plantar incision should bisect metatarsal heads
on a parabola
 Dorsal incision should be more proximal to met
heads, also on a parabola (ensures creation of
Plantar flap)
 Plantar flap must be longer to allow closure with
less tension
 Plantar skin was designed for weight bearing!

Transmetatarsal Amputation
Technique
 Preserve Tibialis Anterior and Peroneus Brevis to
prevent Equinus or Equinovarus deformity
 Preserve as much viable soft tissue as possible
as to prevent focal proximity of bone underlying
skin
 De-bulk as needed, including resection proximally
and under tension of tendon remnants

Transmetatarsal Amputation
Incision Guide
Taylor Bell’s
Foot

Bisect Metatarsal Heads for
Plantar Incision

Creating the Plantar Flap

Carry Incision to Bone

Bevel and Create Parabola
 Resect metatarsals
proximally on angle to
reduce areas of focal
pressure
 Resect soft tissue
attachments working
distally, on underside
of detached
metatarsals

Initial Check of Flap
De-bulk soft tissue and resect additional bone proximally, if needed
Checking to ensure closure with minimal tension and areas of
focal pressure, both plantarly and along incision

Initial Check of Flap

Closure and Final Appearance

Transmetatarsal Parabola
 Bony resection of
metatarsals at mid-
shaft or more proximal
 Create a Parabola

Reducing Focal Pressure by
Proper Beveling of Metatarsals
 Resect metatarsals on angle from Distal-Superior
to Proximal-Inferior in order to bevel, thus
reducing focal pressure
 May also bevel and round the 1st medially and the
5th laterally

Closure to Healing
3.0 vicryl for Subcutaneous tissue
3.0 nylon for Skin
Remove drain or packing after 1-2 days
Reinforce incision with Steri-strips

Final Result

When Does 3 Not Equal 3?
“Form Fits Function”

More Proximal Level
 Consider a more
proximal level
amputation if enough
viable tissue is present
and adequate
perfusion is observed
 Lisfranc’ s or Chopart’s
amputations should be
considered before
proceeding to BKA

Proof That Sometimes
Less Can Be More
Patient now ambulatory with AFO
(Ankle Foot Orthosis) and Extra
Depth Shoes

Tendo Achilles Lengthening?
 What causes breakdown and re- ulceration after TMA?
Equinus is one consideration, and calcification of achilles tendon may cause
equinus and exacerbate the plantaflexed position
Individual Plantarflexed Metatarsals may also be a cause of focal pressure
New bone callus at resection sites; Wolf ’s Law; new focal areas of pressure (greater
in the ambulatory patient)
Resection of bone distal to surgical neck of metatarsal increased incidence of
increased
Hypertrophic Bone Formation by 4 x, so resect metatarsals more proximally
Do not perform TAL if patient is not highly ambulatory

“Toes Are Overrated!”

THANK YOU !!!

Additional References

 Gregory JL, Peters V, Harkless L. Amputations in the Foot. Comprehensive Textbook of Foot Surgery. Mc Glamry ED, Banks
AS, Downey MS, Editors. 2 nd Edition. Williams and Wilkins. 1992. 1390-1408.
1390-

 Anthony T, et al. Transmetatarsal Amputation: Factors Predicting Need for Amputation Revision and Post Procedure
Ambulatory Status. Association of VA Surgeons Conference. Cincinnati, OH. May 9-11, 2006
9-

 Rezyleman A. Essential Pointers on Doing Partial Foot Amputations. Podiatry Today.

 Salonga C and Blume P. A Guide to Transmetatarsal Amputations in Patients with Diabetes. July, 2006.

 Steinberg JS, Morgan J, Guerra JD. Hypertrophic Bone Formation: Be Prepared for this Unpredictable Complication in
Diabetic Foot Amputations. Podiatry Management. Nov/Dec. 2006. 113-120.
113-