Soft-tissue and osseous techniques to balance forefoot and midfoot amputations

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

METHODS

A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

STRUCTURE

Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

METHODS

A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

STRUCTURE

Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

Midfoot Amputations as Adjuncts to Limb Preservation

Midfoot amputations are viable options for limb preservation in cases of forefoot infection, diabetic ulcers, critical limb ischemia, trauma, or malignancy to avoid major lower-extremity amputation. Each level of midfoot amputation has limitations to consider including wound healing problems, soft-tissue contracture, or need for revisional amputations. However, some of these facets can be addressed perioperatively. Each midfoot amputation has benefits as viable options for limb and functional preservation and to avoid major limb amputation. There currently is no set guideline for level of midfoot amputation in patients with critical limb ischemia. Levels of amputation are determined by multiple factors including but not limited to degree of tissue loss, vascular status, the ability to preserve function, surgeon experience, and pertinent patient factors. This approach to limb salvage is best performed from a multi-disciplinary perspective.

A Comparative Analysis of Functional and Patient-Reported Outcomes Following Lisfranc and Chopart Amputations in High-Risk Limb Salvage Patients

Midfoot amputations provide an opportunity for limb salvage through preservation of a weightbearing limb. However, the longevity of midfoot amputations is threatened by restrictions in surface area and risks of skin breakdown. To better inform decisions surrounding the level of amputation, we sought to compare outcomes of high-risk individuals who underwent Lisfranc or Chopart amputations. A single-center retrospective cohort study was performed from November 2013 to September 2022 of adult patients who underwent Lisfranc or Chopart amputations. Patients were stratified into cohorts based on the amputation type. Outcomes included postoperative rates of re-amputation, functional status, mortality and patient-reported outcome measures in the form of Lower Extremity Functional Scale scores. Sixty-six patients were identified; of which, 45 underwent Lisfranc amputation, and 21 underwent Chopart amputation. Median Charlson Comorbidity Index was 7, signifying a substantial comorbidity burden. By median follow-up of 14 (Interquartile range: 28) months, 31 patients (36%) progressed to higher-level amputation, and most patients were ambulatory (n = 38, 58%). Overall rates of re-amputation, ambulatory status, and mortality were comparable between groups. Re-amputation to another midfoot amputation was more common among the Lisfranc cohort (n = 16, 36% vs n = 1, 5%), whereas re-amputation to BKA was more prevalent among the Chopart cohort (Chopart: n = 7, 33% vs Lisfranc: n = 7, 16%; p = .011). Average Lower Extremity Functional Scale scores were similar between groups and corresponded to a maximal function of 48%. Lisfranc and Chopart amputations have the potential to be efficacious limb salvage options in high-risk patient populations in conjunction with intraoperative biomechanical optimization and optimal preoperative patient selection.

Minor Forefoot Amputations in Patients with Diabetic Foot Ulcers

The prevalence of diabetes mellitus, particularly type 2 diabetes, is increasing worldwide. Also, the incidence of both lower limb revascularizations and amputations is increasing. We have less transtibial amputations due to improved diabetes care, but also due to modern treatments, vascular surgery, and development of plastic surgery. With well-planned minor amputations, more limbs can be saved. Minor limb-saving amputations are preferred especially to older diabetes patients, because they have a high-risk contralateral amputations. Losing both limbs causes major problems for patients and their life, risk for lifetime ward is high.

Are Transmetatarsal Amputations a Durable Limb Salvage Option? A Single-Institution Descriptive Analysis

In limb and life-threatening diabetic foot infections, transmetatarsal amputations are often indicated as a limb salvage procedure. The aim of this study is to analyze the long-term durability of initially successful transmetatarsal amputations in the diabetic population. We defined a successful transmetatarsal amputation as one which had clinical healing 1 year after surgery. A retrospective review of transmetatarsal amputations completed at our institution over an 11-year period was performed. We identified 83 amputations that met inclusion criteria. The mean follow-up was 4 years. The mean time to surgical healing was 109.8 days. After successfully healing the transmetatarsal amputation the long-term outcomes were analyzed. Re-ulcerations occurred in 44% of the transmetatarsal amputations a mean of 15 months after surgical healing. Patients who re-ulcerated were noted to be significantly younger (p value 0.02) with a significantly higher preprocedure hemoglobin A1c (p value < .001). Additional procedures after successful healing included 13 (15.66%) revision surgeries and 12 (14.46%) more proximal amputations. While transmetatarsal amputations remain a viable and durable limb preserving surgery, all patients who have undergone a transmetatarsal amputation should be monitored lifelong as they remain at risk for re-ulceration and more proximal amputation.

Vascularized Pedicled Fibula Onlay Bone Graft Augmentation for Complicated Tibiotalocalcaneal Arthrodesis With Retrograde Intramedullary Nail Fixation: A Case Series

Tibiotalocalcaneal arthrodesis stabilized with retrograde intramedullary nail fixation is associated with a high incidence of complications. This is especially true when performed with a bulk structural allograft and poor soft tissue quality. In select high-risk limb salvage cases, we have augmented tibiotalocalcaneal arthrodesis procedures stabilized using retrograde intramedullary nail fixation with a vascularized pedicled fibular onlay bone graft. We present the data from 10 such procedures with a mean follow-up period of 10.9 ± 5.4 (range 6 to 20) months involving 10 patients (9 males and 1 female). The etiology was avascular osteonecrosis of the talus and/or distal tibia and a resultant large volume cavitary bone defect (8 ankles), severe equinocavovarus contracture (1 ankle), and failed total ankle replacement (1 ankle). A frozen femoral head bulk allograft was used twice, a whole frozen talus allograft once, and a freeze-dried calcaneal allograft once. The fibula was mobilized with intact musculoperiosteal perforating branches of the peroneal artery as a vascularized pedicle onlay bone graft fixated with a screw and washer construct. The mean fibular graft length was 10.2 ± 2.3 cm. The mean interval to radiographic fusion was 2.6 ± 0.6 months and to weightbearing was 3.1 ± 1.4 months. Two stable bulk allograft-host bone and fibular graft-host bone nonunions occurred after intramedullary nail hardware failure. Tibiotalocalcaneal arthrodesis augmented by vascularized pedicled fibular graft stabilized with retrograde compression intramedullary nail fixation offers a reliable option for complex salvage situations when few other options exist.

Soft Tissue Balancing After Partial Foot Amputations

Partial foot amputations have become common procedures for the foot and ankle surgeon as part of a limb salvage practice. These procedures are highly technique driven and there are many complex factors that affect the outcome and longevity. Appropriate surgical planning must be used with every partial foot amputation to ensure a plantigrade foot with the least potential for future breakdown. When performed appropriately, these amputations have great success with lower energy expenditure and decreased mortality compared with below-knee or above-knee amputations.

What's new in wound treatment: a critical appraisal

With the growing demand for the specialized care of wounds, there is an ever expanding abundance of wound care modalities available. It is difficult to identify which products or devices enhance wound healing, and thus, a critical and continual look at new advances is necessary. The goal of any wound regimen should be to optimize wound healing by combining basic wound care modalities including debridement, off-loading, and infection control with the addition of advanced therapies when necessary. This review takes a closer look at current uses of negative pressure wound therapy, bioengineered alternative tissues, and amniotic membrane products. While robust literature may be lacking, current wound care advances are showing great promise in wound healing.

Effect of Osteogenic Progenitor Cell Concentration on the Incidence of Foot and Ankle Fusion

The use of biologics, namely demineralized bone matrix, bone marrow aspirate (BMA), and other growth factors, has gained popularity in foot and ankle surgery for use in compromised hosts or high-risk situations. Our research has shown the concentration of these pluripotent cells was greatest in the iliac crest. A medical record and radiographic review was performed to compare the effect of BMA harvest site osteogenic progenitor cells on the incidence of fusion. Radiographs were reviewed for radiographic evidence of trabecular bridging in 2 or more views. If fusion occurred, the number of osteogenic progenitor cells found in the combined BMA at surgery was recorded. A total of 33 patients were included in the present study. Of the 33 patients, 32 (97.0%) had radiographic fusion at a mean of 13 ± 6 (range 8 to 30) weeks, and 1 (3.0%) experienced nonunion and required revision. The patient procedures were as follows: 18 (54.5%) hindfoot arthrodeses, 8 (24.2%) forefoot arthrodeses, 4 (12.1%) fractures, and 3 (9.1%) isolated ankle fusions. The mean colony-forming units for the patients with fusion was 20.3 ± 23.5 (range 0.0 to 107.0). In the patient with nonunion, it was 0.20 colony-forming unit. Our comparison of the incidence of fusion with the use of osteogenic progenitor cells from 3 anatomic sites showed a low incidence of complications and a high incidence of fusion. No association was found between the BMA concentration and the incidence of fusion, suggesting a minimum concentration and biologic potential of pluripotent cells is necessary to achieve the clinical effect of fusion.

Incidence of re-amputation following partial first ray amputation associated with diabetes mellitus and peripheral sensory neuropathy: a systematic review

Diabetes mellitus with peripheral sensory neuropathy frequently results in forefoot ulceration. Ulceration at the first ray level tends to be recalcitrant to local wound care modalities and off-loading techniques. If healing does occur, ulcer recurrence is common. When infection develops, partial first ray amputation in an effort to preserve maximum foot length is often performed. However, the survivorship of partial first ray amputations in this patient population and associated re-amputation rate remain unknown. Therefore, in an effort to determine the actual re-amputation rate following any form of partial first ray amputation in patients with diabetes mellitus and peripheral neuropathy, the authors conducted a systematic review. Only studies involving any form of partial first ray amputation associated with diabetes mellitus and peripheral sensory neuropathy but without critical limb ischemia were included. Our search yielded a total of 24 references with 5 (20.8%) meeting our inclusion criteria involving 435 partial first ray amputations. The weighted mean age of patients was 59 years and the weighted mean follow-up was 26 months. The initial amputation level included the proximal phalanx base 167 (38.4%) times; first metatarsal head resection 96 (22.1%) times; first metatarsal-phalangeal joint disarticulation 53 (12.2%) times; first metatarsal mid-shaft 39 (9%) times; hallux fillet flap 32 (7.4%) times; first metatarsal base 29 (6.7%) times; and partial hallux 19 (4.4%) times. The incidence of re-amputation was 19.8% (86/435). The end stage, most proximal level, following re-amputation was an additional digit 32 (37.2%) times; transmetatarsal 28 (32.6%) times; below-knee 25 (29.1%) times; and LisFranc 1 (1.2%) time. The results of our systematic review reveal that one out of every five patients undergoing any version of a partial first ray amputation will eventually require more proximal re-amputation. These results reveal that partial first ray amputation for patients with diabetes and peripheral sensory neuropathy may not represent a durable, functional, or predictable foot-sparing amputation and that a more proximal amputation, such as a balanced transmetatarsal amputation, as the index amputation may be more beneficial to the patient. However, this remains a matter for conjecture due to the limited data available and, therefore, additional prospective investigations are warranted.

Preserving functional capacity as opposed to tissue preservation in the diabetic patient: a single institution experience

The authors performed a retrospective review of prospectively collected data of all diabetic patients who underwent transmetatarsal amputation (TMA) for toe gangrene or neuropathic ulceration from May 2006 to June 2009. Twenty-nine TMAs were performed in diabetic patients during the study period, including 24 men and 5 women with a mean +/- SD age of 66.3 +/- 7.5 years. The indications for TMA were gangrene of > or = 2 digits in 12 patients (41%) and neuropathic ulceration with underlying osteomyelitis or abscess and a concomitant dysfunctional forefoot in 17 patients (59%). Of the 12 patients who presented with toe gangrene, 7 (58%) underwent endovascular intervention and 5 (42%) underwent open vascular bypass. Equinus contracture was present in 27 patients (93%), and 26 (96%) of these patients underwent tendo-Achilles lengthening or gastrocnemius recession. Correction of equinus contracture was not performed in 1 patient as it was deemed not feasible. Forefoot varus deformity was present in 22 (76%) patients, and balancing was performed in 17 of these patients (77%) with skeletal stabilization or tendon transfer. Balancing was not performed in the remaining patients as it was not necessary or not feasible. Sixteen patients (55%) healed primarily and 5 patients (17%) developed minor wound separation that healed via secondary intention. An additional 4 patients were able to maintain functional revision procedures confined to the foot (1 TMA revision, 3 Chopart amputations). Three patients (10%) required below-knee amputation, and there were 2 deaths (7%) during the time period. Functional amputation confined to the foot was achieved in 86% of ambulatory diabetic patients. These results support a more aggressive initial approach in ambulatory diabetic patients with multiple digital ulcerations, allowing this patient population to remain functional and avoid multiple reoperations and ultimately major amputation.

Extra-articular ankle stabilization: a case series

Maintenance of the foot at 90 degrees to the lower leg following posterior calf lengthening or to prevent an equinus contracture in situations in which splint, cast, or external fixation is deemed inappropriate is a challenge. The author presents an observational case series involving 9 extra-articular ankle stabilizations performed in 9 consecutive patients. Each patient underwent his or her index surgery followed by percutaneous placement of 2 smooth 2.8-mm or larger diameter Steinmann pins extra-articular to the ankle joint. There were 6 men and 3 women with a mean age of 56.1 years (range, 31-73 years). Five patients had diabetes with peripheral neuropathy, 2 had critical limb ischemia, 1 had alcohol-induced neuropathy, 1 had lupus, and 1 was an active smoker. Eight patients had posterior calf lengthening, and 1 had open metatarsal fractures with severe soft-tissue disruption with an inability to use splint immobilization. Three patients had a transmetatarsal amputation, 2 patients had Chopart amputations, 2 patients had forefoot plastic surgery reconstructive procedures, 1 had a complex Charcot reconstruction, and 1 had a splittibialis anterior tendon transfer. Extra-articular ankle stabilization fixation was retained for a mean of 5.5 weeks (range, 2-10 weeks). Mean follow-up was 12 months (range, 1-17 months). All extra-articular stabilization procedures were deemed successful. When properly performed, extra-articular stabilization to maintain the foot at 90 degrees to the lower leg represents a safe, simple, reliable, and minimally invasive technique useful in situations in which traditional splint or cast immobilization is not possible and when external fixation is deemed inappropriate.

Flexor hallucis longus and extensor digitorum longus tendon transfers for balancing the foot following transmetatarsal amputation

Transmetatarsal amputation is a useful surgical procedure that is applicable to the treatment of the dysvascular, neuropathic, and/or traumatized forefoot. Because of the loss of the insertions of some of the extrinsic pedal musculature, transmetatarsal amputation is known to be associated with imbalance of the residual foot, and this can lead to complications related to cutaneous compromise, as well as difficulties with bracing and shoe fit. In this techniques report, we describe a combination of tendon transfers that use flexor hallucis longus and extensor digitorum longus, which can be useful in preventing pedal imbalance following transmetatarsal amputation.

Minimum-incision ray resection

Ray resection for localized necrosis, infection, and osteomyelitis is an accepted procedure allowing removal of the diseased toe and metatarsal. The traditional approach involves a rather lengthy incision and dissection that can compromise the vascular supply to the remaining forefoot. The use of minimum incision techniques to perform metatarsal ray resection as presented here represents a simple, reliable, and easily reproduced procedure that limits soft-tissue dissection and the associated wound healing-related complications inherent to the traditional approach. Following minimum incision metatarsal ray resection, the resultant defect from the toe amputation can be primarily closed, covered with a split-thickness skin graft, or closed in delayed primary fashion with the use of a mini-external fixation device. The authors present the proper indications and a step-by-step guide for performing minimum incision metatarsal ray resection with and without the supplemental use of mini-external fixation to close the soft-tissue defect about the toe amputation site.

Internal pedal amputations

Internal pedal amputation consists of resection of the metatarsals, midtarsal bones, or talus with preservation of the toes and soft-tissue envelope. Although used in the past for the treatment of tuberculosis within the pedal skeleton, internal pedal amputations have become almost forgotten, historical procedures. However, following internal pedal amputations of a diabetic patient, the foot undergoes significant contracture that results in a stable, functional, foreshortened residual foot capable of being protected in custom-molded shoe gear with external or in-shoe orthoses. The author presents the surgical approach and postoperative treatment regime for each form of internal pedal amputation, as well as "pearls" for success.

Tenotomy and tendon transfer about the forefoot, midfoot and hindfoot

Tendon lengthening and transfer are essential surgical procedures for every foot and ankle surgeon to master, because they are useful in restoring balance and correcting flexible foot deformities. These techniques are even more useful in treating the high-risk patient, because they involve minimal soft-tissue injury and maximum preservation of vascularity. The primary goal of this article is to supplement the foot and ankle surgeon's options for treating static and dynamic foot deformities in the high-risk patient by discussing useful tendon lengthening and transfer procedures about the forefoot, midfoot, and hindfoot.