How are transmetatarsal lower-extremity amputations performed?

Answer

Tourniquets are used on a discretionary basis in patients with vascular disease.^[31]The extremity is prepared in a standard fashion. The skin incision is made as distal as is feasible, and dorsal and plantar flaps are created. Attention should be paid to ensuring viable margins so as to minimize the risk of subsequent osteomyelitis.^[32]The flexor and extensor muscle groups are elevated as one musculofascial flap. The vessels are isolated and ligated, and the digital nerves are separated, distracted, and ligated at a more proximal level.

Osteoperiosteal flaps are elevated from the first and fifth metatarsals. The metatarsals are transected from dorsal to plantar at approximately 15º, with a cascade of shortening as one proceeds laterally. Care is taken to smooth off any rough borders with a file and to not leave any significant prominence beneath the skin. The osteoperiosteal flaps are sutured end-to-end and to each metatarsal, covering (closing) the exposed diaphysis. The flexor and extensor groups are sutured to each other through the fascial attachments, forming the myoplasty.

If used, the tourniquet is released and bleeding is controlled. The skin is contoured to the underlying myoplasty, allowing for a smooth transition. Penrose drains are placed for hematoma decompression. Sterile dressings and a well-padded posterior splint are applied.

The splint is removed after 2-7 days. Physical therapy is also instituted for patient education on transfers, desensitization of the residual extremity, aerobic conditioning, and upper-body strengthening. Full weightbearing is initiated at 4-6 weeks or pending wound healing.

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Media Gallery

Image that depicts the various levels of lower-extremity amputations.

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Author

Janos P Ertl, MD Assistant Professor, Department of Orthopedic Surgery, Indiana University School of Medicine; Chief of Orthopedic Surgery, Wishard Hospital; Chief, Sports Medicine and Arthroscopy, Indiana University School of Medicine

Janos P Ertl, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Hungarian Medical Association of America, Sierra Sacramento Valley Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

William J Brackett, MD Research Assistant, Department of Orthopedic Surgery, Indiana University School of Medicine

Disclosure: Nothing to disclose.

William Ertl, MD Clinical Assistant Professor, Department of Orthopedics, University of Oklahoma College of Medicine

Disclosure: Nothing to disclose.

James W Pritchett, MD Chief of Orthopedic Surgery, Swedish Orthopedic Institute; Active Staff, Swedish Medical Center

James W Pritchett, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, Washington State Medical Association, Association of Bone and Joint Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS Professor of Orthopedic Surgery, Chief, Division of Foot and Ankle Surgery, Director, Foot and Ankle Fellowship Program, Department of Orthopedic Surgery, University of Texas Medical Branch School of Medicine

Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Texas Orthopaedic Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Styker.

Additional Contributors

James K DeOrio, MD Professor of Orthopedics, Director, Duke Foot and Ankle Fellowship, Duke University Medical Center, Duke University School of Medicine; Associate Professor, Mayo Clinic College of Medicine; Clinical Assistant Professor, F Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences

James K DeOrio, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, Association of Graduates, United States Air Force Academy, Doctors Mayo Society, Mayo Clinic Alumni Association, Society of Air Force Clinical Surgeons, Society of Military Orthopaedic Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Exactech; Treace Medical; Additive; Mirus<br/>Serve(d) as a speaker or a member of a speakers bureau for: Exactech; Treace Medical; Additive; Mirus; WoultersKluwer.

How are transmetatarsal lower-extremity amputations performed?

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