What type of amputation is indicated for an elderly diabetic patient with gangrene in the forefoot: A. Syme’s amputation (at the level of the ankle, preserving the heel pad), B. Transmetatarsal amputation, or C. Below-knee amputation?

From the Guidelines

For an old age diabetic patient with gangrene in the forefoot, a transmetatarsal amputation (option B) would be the most appropriate choice. This procedure involves removing the forefoot at the level of the metatarsal bones while preserving the midfoot and hindfoot. Transmetatarsal amputation is preferred in this case because it addresses the gangrenous tissue while maintaining maximum limb length and function, as suggested by the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1.

Key Considerations

• This level of amputation allows the patient to maintain better mobility and weight-bearing capacity compared to more proximal amputations.
• For diabetic patients with forefoot gangrene, preserving as much viable tissue as possible is crucial for rehabilitation outcomes, as highlighted in the IWGDF guidance on the diagnosis and management of foot infections in persons with diabetes 1.
• Syme's amputation would be too aggressive since the infection is limited to the forefoot, while below knee amputation would unnecessarily sacrifice healthy tissue.
• The transmetatarsal approach also provides adequate blood supply for healing, which is particularly important in diabetic patients who often have compromised vascular status, as noted in the 2024 ESC guidelines 1.

Post-Operative Care

• Post-operatively, the patient will require specialized footwear and physical therapy to adapt to the altered biomechanics of walking.
• Pre-amputation revascularization enhances wound healing, and in cases of extensive necrosis or infectious gangrene, primary major amputation without revascularization may be preferable to avoid complications, as suggested by the 2024 ESC guidelines 1.
• The goal is to balance preservation of tissue with the need for a functional foot, considering the patient's overall health and mobility, in line with the recommendations from the IWGDF guidance 1.

From the Research

Amputation Options for Diabetic Patients with Gangrene

• The most suitable amputation option for an old age diabetic patient with gangrene in the forefoot is Transmetatarsal amputation (B), as it appears to be the most effective in terms of limb salvage rates and in maintaining foot and ankle biomechanics 2.
• This type of amputation is a valuable option for diabetic foot gangrene that can prevent major limb loss and minimize loss of function, thus improving the quality of life for diabetic patients 2.
• Studies have shown that transmetatarsal amputation can be expected to heal in a majority of diabetic patients after adequate revascularization, although the healing process cannot be predicted by angiographic findings 3.
• Other options, such as Syme's amputation (A) and Below knee amputation (C), may not be as suitable for this specific case, as Syme's amputation is typically performed at the level of the ankle, preserving the heel pad, and below knee amputation is a more extensive procedure that may not be necessary for gangrene limited to the forefoot.

Considerations for Amputation

• The decision to perform a transmetatarsal amputation should be based on the judgment of an experienced physician, taking into account factors such as ankle brachial indices, toe pressures, laser Doppler skin perfusion pressures, angiography, and Doppler assessment of foot vasculature 2.
• The presence of peripheral arterial disease, severe ankle-brachial index, and previous revascularization attempts may be associated with poor outcomes of transmetatarsal amputation 4.
• Efforts should be made to achieve primary wound closure, and tailored wound closure, adjuvant local treatments, and the choice of the most appropriate antibiotic therapy are pivotal elements for the success of transmetatarsal amputation procedures 2.