FUNCTIONAL FOOT SALVAGE AFTER EXTENSIVE PLANTAR EXCISION AND AMPUTATIONS PROXIMAL TO THE STANDARD TRANSMETATARSAL LEVEL

Purpose: It is generally accepted that when necrosis extends proximal to the transmetatarsal level a viable and functional foot can no longe r be preserved and a major (above- or below-knee) amputation must be p erformed. However, with continuing advances in operations for limb sal vage we felt the need to reexamine this concept. Methods: In 1983 we i nitiated a prospective study to evaluate the role of extended foot amp utations. All ambulatory patients with necrosis extending proximal to the transmetatarsal level (but not involving the whole foot) were incl uded in the study. Among the 21 patients studied amputations ranged fr om open guillotine transmetatarsal amputation to removal of the medial or lateral three fifths of the foot. Five of these patients had adequ ate pedal circulation by clinical and laboratory criteria. The remaini ng 16 required vascular reconstruction to improve pedal how. Results: Eighteen (86%) of 21 patients had complete healing of the foot amputat ions and were ambulatory at the time of discharge from the hospital. T wo patients required early above- or below-knee amputations. Three add itional patients sustained limb loss in the follow-up period. The cumu lative graft patency rate was 94% at 12 months. The cumulative limb sa lvage rate at 24 months was 84%. The operative mortality rate was 1 (5 %) of 21. Conclusion: Our experience in a small number of patients sug gests that functional foot salvage is possible even when necrosis or g angrene extends proximal to the transmetatarsal level.