[Minor amputations - a maxi task. Part 1: From the principles to transmetatarsal amputation]

The care of transmetatarsal amputation in diabetic foot gangrene

Diabetic foot ulcerations may determine minor or major amputation, with a high impact on patients' life expectation and quality of life and on economic burden. Among minor amputations, transmetatarsal amputation (TMA) appears to be the most effective in terms of limb salvage rates and in maintaining foot and ankle biomechanics. In spite of this, TMA needs particular pre- and postoperative management in order to avoid the frequent failure rates. A systematic review was undertaken of studies concerning TMA and its care in diabetic foot gangrene. Studies were identified by searching the MEDLINE, Scopus and Science Direct databases until 13 January 2016. All studies were assessed using the Downs and Black quality checklist. Of the 348 records found, 86 matched our inclusion criteria. After reading the full-text articles, we decided to exclude 35 manuscripts because of the following reasons: (1) no innovative or important content, (2) no multivariable analysis, (3) insufficient data, (4) no clear potential biases or strategies to solve them, (5) no clear endpoints and (6) inconsistent or arbitrary conclusions. The final set included 51 articles. In the current literature, there are less data about TMA, indication for the selection of patients, outcomes and complications. Generally, the judgment of an experienced physician is one of the best indicators of subsequent healing. Ankle brachial indices, toe pressures, laser Doppler skin perfusion pressures, angiography and Doppler assessment of foot vasculature may help physicians in this decision. In any case, despite the presumed lower healing rate, it is reasonable to pursue a TMA in a patient with a higher likelihood of continued ambulation. Furthermore, tailored wound closure, adjuvant local treatments and the choice of the most appropriate antibiotic therapy, when infection occurs, are pivotal elements for the success of TMA procedures. TMA is a valuable option for diabetic foot gangrene that can prevent major limb loss and minimise loss of function, thus improving the quality of life for diabetic patients.

[Hallux amputation]

OBJECTIVE

Debridement of infected tissue with the main aim being the re-establishment of mobilization with preservation of standing and walking ability. Prevention of secondary pressure points or amputations due to inadequate resection or deficient soft tissue cover.

INDICATIONS

In the case of increasing necrosis of the big toe, surgical abrasion and/or amputation is considered unavoidable. Other indications where surgery could be considered include diabetes and its associated angiopathies together with peripheral arterial angiopathy.

CONTRAINDICATIONS

In the case of insufficient blood supply an expansion of the resection margins should be taken into account. If there are possible alternatives to amputation. Surgery for patients with renal failure requiring dialysis associated with increased complication rate.

SURGICAL TECHNIQUE

A dorsal cuneiform resection is performed to facilitate implantation of a plantar skin transplant and wound healing. Important is the resection of bone in a slide oblique technique. Amputation scars should be outside pressure zones. Partial amputations in the area of the first ray as exarticulation or via the individual amputated segments possible (as opposed to toes 2-5).

POSTOPERATIVE MANAGEMENT

Direct postoperative weight-bearing with rigid insole and dispensing aid for 6-8 weeks. Following complete wound healing, foot support with orthopedic arch and transverse strain relief should be advocated, together with a joint roll in ready-made individual shoes.

RESULTS

Both trauma and nontrauma cases were included in our present cohort. A total of 7 cases were surgically revised in 2014 due to superficial skin necrosis that was likely the result of skin tension from the wound stitches.

[Minor foot amputations in diabetic foot syndrome]

OBJECTIVE

The treatment strategy for diabetic foot syndrome must take into account protective sensibility of the foot, open wounds, infection status, and the rules of septic bone surgery. Interventions are classified as elective, prophylactic, curative, or emergency. Amputations in the forefoot and midfoot region are performed as ray amputations (including metatarsal), which can often be carried out as "inner" amputations. Gentle tissue treatment mandatory because of greater risk of revision with re-amputation compared to classical amputation.

INDICATIONS

Good demarcation of infection, acute osteomyelitis, osteolytic lesions, neurotropic ulcer, arterial and venous blood flow to the other toes, gangrene of other toes with metatarsal affection.

CONTRAINDICATIONS

Arterial occlusive disease, infection of neighboring areas, avoidable amputations, poorly healing ulcers on the lower leg.

SURGICAL TECHNIQUE

Primary dorsal approach; minimal incisional distance (5 cm) to minimize skin necrosis risk. Atraumatic preparation, minimize hemostasis to not compromise the borderline perfusion situation. In amputations, plantar skin preparation and longer seams placed as dorsal as possible, either disarticulated and maintain cartilage, or round the cortical metatarsal bone after resection.

POSTOPERATIVE TREATMENT

Diabetes control. Braun splint, mobilization in a shoe with forefoot decompression and hindfoot support, physiotherapy. Antibiotics based on resistance testing. If no complications, dressing change on postoperative day 1. Optimal wound drainage by lowering foot several times a day; drainage removal after 12-24 h. Insoles and footwear optimization.

RESULTS

Amputations require continued attention and if necessary treatment to avoid sequelae. Insufficient treatment associated with recurrent ulceration and altered anatomy.