SLR - May 2023 - Firas Katmeh, DPM, MSH
Title: Presence of a Patent Pedal Arch is the Primary Predictor of Transmetatarsal Amputation Healing and Limb SalvageReference: Glousman BN, Cragon R, Steinberg JS, Evans KK, Attinger CE, Kiguchi MM, Tefera E, Akbari CM. Presence of a patent pedal arch is the primary predictor of transmetatarsal amputation healing and limb salvage. J Vasc Surg. 2023 Jan 28:S0741-5214(23)00267-7. https://doi.org/10.1016/j.jvs.2023.01.184
Level of Evidence:  Retrospective Study, Level IV
Scientific Literature Review 
Reviewed By: Firas Katmeh, DPM, MSH
Residency Program: UF Health - Jacksonville, Jacksonville, FL
Podiatric Relevance: The transmetatarsal amputation (TMA) is the most biomechanically balanced amputation of the foot with the next being a below-the-knee amputation.It’s impact on limb salvage is critical and needs to be fully understood to maximize its success rate and reduce dehiscence and failure rate. As Foot and Ankle Surgeons, our understanding of this amputation must be absolute and surgical technique alone is not the answer. The presence of a pedal arch prior to an amputation should be further investigated with an emphasis on inter-disciplinary management for limb salvage with our vascular colleagues. This article sheds light on the most critical aspect of any surgeon’s work; the ability to heal from surgery.
Methods: A single-institution, retrospective, case-control study of 89 patients who had undergone transmetatarsal amputation and ipsilateral lower extremity arteriography within 1 month before or 6 months after the TMA from 2012 to 2020. They compared patients with TMA healing and non-healing by multivariate analysis to define TMA healing at 30 days and 1 year with the following metrics: Global Limb Anatomic Staging System (GLASS) and evaluation of the tibial runoff vessels. Patients who had undergone an intervention post-TMA, the postintervention GLASS stage was calculated. Follow-up was with the same surgeon with a 30-day and 1-year limb salvage rate calculated.
Results: The presence of a maintained pedal arch had significantly increased rates of healing vs non-healing TMAs [66% vs 23% at 30 days (P<0.01) and 48% vs 18% (P<0.01) at 1 year], however, the presence of a patent pedal arch was no longer a significant predictor at 1 year. No difference was found with GLASS femoropopliteal vs. infrapopliteal staging for TMA healing vs non-healing. Additionally, GLASS inframalleolar (P0) staging was associated with improved limb salvage at 30 days (86% vs 49%; P< 0.01) and at 1 year (79% vs 49%; P<0.01) when compared to non-healing TMAs. There was a 5.50 odds (95% CI 1.15-25.91; P=0.03) of TMA healing at 30 days with a patent pedal arch. The multivariate analysis was 0.89.
Conclusions: The TMA is an important limb salvage option that should always be considered when otherwise facing a more proximal amputation. The patency of the pedal arch is critical when evaluating the success rate of healing with a TMA (66% at 30 days and 48% at 1 year). Despite the retrospective, case-control study design with a small sample size, the importance of multivessel run-off alone beyond the ankle clearly needs to be further investigated. Future studies focusing on pedal arch patency will enhance our understanding of TMA success vs. failure and will assist with mitigation of more proximal amputations.