How are transmetatarsal lower-extremity amputations performed?

Updated: Apr 29, 2021
  • Author: Janos P Ertl, MD; Chief Editor: Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS  more...
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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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