What are the reported outcomes of transmetatarsal amputation (TMA)?

Updated: Apr 29, 2021
  • Author: Palaniappan Lakshmanan, MBBS, MS, AFRCS, FRCS(Tr&Orth); Chief Editor: Erik D Schraga, MD  more...
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Statistics from the 1990s indicated that approximately 10,000 TMAs were performed in the United States, compared with 32,000 above-knee amputations (AKAs) and 22,000 below-knee amputations (BKAs). [5] TMA, when feasible, is the logical preference because it is the only amputation procedure that allows for potential weightbearing.

Rehabilitation from more proximal amputations for peripheral vascular disease (eg, AKAs and BKAs) is seldom a success. Only 5% of amputees mobilize outside the confines of their home with a prosthesis, and most of those who do will become wheelchair-dependent within 5 years. In theory, TMAs should yield better mobilization percentages. In a study of 4965 nursing-home residents who underwent amputation, patients who underwent BKA (n = 1596) or AKA (n = 2879) recovered more slowly than those who underwent TMA (n = 490) and did not return to baseline function by 6 months. [6]

A weightbearing residuum is not the only advantage of TMA: Studies have shown that it is associated with a lower mortality than either AKA or BKA. [7, 8] In one study, TMA had a 30-day postoperative mortality of 3%, [9] whereas in another study, BKA had a 30-day postoperative mortality of 6.3% and AKA had a 30-day postoperative mortality of 13.3%. [10]

In a study comparing digital amputation (n = 77) with transmetatarsal amputation (n = 70) in 147 diabetic patients with gangrenous toes, Elsherif et al found that transmetatarsal amputation offered better outcomes, with a lower reintervention rate (15.7% vs 29.9%), a shorter median hospital stay (17 days vs 20 days), fewer theater trips, and a longer time without toxicity (346 days vs 315 days). [11] However, the differences did not reach statistical significance.

Tan et al retrospectively evaluated outcomes after TMA for peripheral arterial disease (PAD) limb salvage in 147 Asian patients and undertook to identify risk factors associated with TMA failure. [12] They reported a success rate of 63% for PAD limb salvage TMA and noted that diabetes was an independent predictor of TMA failure. Patients in whom TMA failed were found to be at increased risk for nosocomial infections and 30-day readmissions.

Adams et al assessed 3-year mortality and morbidity in 375 patients who underwent nontraumatic TMA, examining variations in TMA complication rates according to sex, age, race, and comorbid conditions. [13] After a nontraumatic TMA, 136 (36.3%) patients died within 3 years, 138 (36.8%) required a more proximal limb amputation, and 83 (22.1%) healed without complications. Patients with nonpalpable pedal pulses were three times as likely to require a proximal limb amputation, almost twice as likely to die within 3 years, and more than twice as likely not to heal after the TMA. Patients with end-stage renal disease were three times as likely to die within 3 years.

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