title: Transmetatarsal amputation: assessment of current selection criteria.
abstract: BACKGROUND
  Transmetatarsal amputation (TMA) is an operation designed to remove a limited area of irremediable tissue ischemia and/or infection and preserve limb function. Patients are selected for TMA based on degree of tissue loss/infection, adequacy of tissue perfusion at the transmetatarsal level, current ambulatory status, and estimation of the likelihood of postprocedure ambulation. The purpose of this study was to assess the validity of these selection criteria.
  
  
  METHODS
  An institutional review board-approved retrospective review was conducted of all patients undergoing TMA from January 1, 1997, until January 1, 2006. Information was collected on patient demographics, medical comorbidity, and clinical and surgical variables. Outcome measures included the proportion of patients requiring amputation revision to a more proximal level and ambulatory status at last follow-up.
  
  
  RESULTS
  Fifty-two TMAs were performed. In 35 procedures, the skin was left open, and in 17 TMA was closed primarily. Primary indications for the procedure were vascular insufficiency or infection in 50 of 52 patients, whereas 2 patients required amputation for malignancy. The majority (46/52, 89%) of patients were diabetic. After the index TMA, 85 additional operations were required. Only 9 patients (18%) underwent a single operation. Revision of the TMA to a more proximal level was required in 29 of 52 (56%) patients, resulting in 4 Syme, 20 transtibial, and 5 transfemoral amputations. Non-insulin-dependent diabetes was associated with an increased likelihood of revision to a more proximal amputation (odds ratio [OR] = 5.4; 95% confidence interval [CI], 1.2-24). At the time of last follow-up (median 18 months), 37 of 50 (74%) patients were ambulatory (83% for TMAs and 67% for more proximal amputations, P = 0.18). Prior vascular procedures were associated with a significantly decreased likelihood of ambulation (OR = 14; 95% CI, 1.9-103).
  
  
  CONCLUSIONS
  Although most patients retain the ability to ambulate after TMA, multiple operations should be anticipated in the majority of patients and revision of a TMA to a more proximal level may be required. These data suggest that current selection criteria for TMA may be inadequate.
authors.affiliation: Section of General Surgery, Surgical Service, VA North Texas Health Care System, 4500 S Lancaster Rd, Dallas, TX 75216, USA. Thomas.anthony@UTSouthwestern.edu
authors.forename: Thomas
authors.initials: T
authors.lastname: Anthony
authors.forename: James
authors.initials: J
authors.lastname: Roberts
authors.forename: J Gregory
authors.initials: JG
authors.lastname: Modrall
authors.forename: Sergio
authors.initials: S
authors.lastname: Huerta
authors.forename: Massimo
authors.initials: M
authors.lastname: Asolati
authors.forename: John
authors.initials: J
authors.lastname: Neufeld
authors.forename: Betty
authors.initials: B
authors.lastname: Parker
authors.forename: Weibin
authors.initials: W
authors.lastname: Yang
authors.forename: George
authors.initials: G
authors.lastname: Sarosi
mesh_terms: D000671:Amputation, Surgical; D015897:Comorbidity; D003327:Coronary Disease / Q000453:epidemiology; D003925:Diabetic Angiopathies / Q000453:epidemiology / Q000601:surgery*; D005260:Female; D005528:Foot / Q000098:blood supply*; D006801:Humans; D007511:Ischemia / Q000453:epidemiology / Q000601:surgery*; D007902:Length of Stay; D016015:Logistic Models; D008297:Male; D008684:Metatarsus / Q000601:surgery*; D008875:Middle Aged; D018579:Patient Selection; D016491:Peripheral Vascular Diseases / Q000453:epidemiology; D010991:Plethysmography; D012086:Reoperation; D012189:Retrospective Studies