What to assess 2 months post transmetatarsal (across the metatarsal bones) foot amputation?

Post-Transmetatarsal Amputation Assessment at 2 Months

At 2 months post-transmetatarsal amputation, comprehensive assessment should focus on wound healing status, vascular supply, infection control, and biomechanical function to prevent complications and optimize outcomes.

Wound Assessment

• Evaluate for complete wound healing (primary healing occurs at a median of 31 days in successful cases 1)
• Assess for:
  • Signs of infection (erythema, warmth, tenderness, pain, induration, purulent secretions) 2
  • Wound size, depth, and undermining 2
  • Presence of necrotic tissue requiring debridement 2
  • Adequacy of wound closure (primary closure has better outcomes with 78.8% healing rate vs. 37.9% for secondary healing) 3

Vascular Assessment

• Check for arterial ischemia which is present in up to 50% of diabetic foot cases 2:
  • Palpate pedal pulses (posterior tibial and dorsalis pedis)
  • Measure ankle-brachial index (ABI) - note that higher ABI values correlate with better healing outcomes 4
  • Consider toe pressure measurement with toe-brachial index (TBI >0.7 makes PAD less likely) 2
  • Assess for tissue perfusion (pallor on elevation, dependent rubor)
  • Consider vascular imaging if clinical signs of inadequate perfusion are present 2

Infection Surveillance

• Evaluate for osteomyelitis in the residual metatarsal bones, as positive bone margins significantly correlate with failed healing 1
• Check for:
  • Elevated inflammatory markers (CRP, ESR, WBC) if clinically indicated 2
  • Probe-to-bone test if wound is not fully healed 2
  • Consider plain radiographs to assess for bone changes 2

Biomechanical and Functional Assessment

• Evaluate weight-bearing status and ambulatory function:
  • Independent ambulation is achieved in 73% of patients with healed TMAs vs. only 14% with non-healed TMAs 5
• Assess for:
  • Foot deformities that may lead to abnormal pressure points 2
  • Proper offloading strategies being used 2
  • Need for therapeutic footwear or custom orthotics 2
  • Gait pattern and stability 2

Offloading and Pressure Redistribution

• Implement appropriate offloading device:
  • Non-removable knee-high device (total contact cast or walker) is strongly recommended once infection is controlled 2
  • Evaluate need for custom therapeutic footwear for long-term use 2
  • Assess for pressure points that could lead to new ulcerations 2

Metabolic Control

• Check HbA1c levels (values >8% may impact healing) 1
• Assess nutritional status (serum albumin is a significant predictor of wound healing) 4
• Evaluate renal function (dialysis-dependent renal failure is associated with higher mortality) 5

Follow-up Planning

• Determine appropriate follow-up interval based on healing status
• Consider multidisciplinary team involvement:
  • Vascular surgery if concerns about perfusion
  • Infectious disease if ongoing infection concerns
  • Physical therapy for gait training and rehabilitation
  • Orthotist for custom footwear needs

Complication Surveillance

• Monitor for signs that may indicate need for reamputation:
  • Reamputation rates can be as high as 34% at 1-year follow-up 6
  • Major amputation rates around 12.6% at 1-year 6
  • Mortality rates: 0% at 30 days, 5.1% at 1 year, 20.5% at 5 years 1

By systematically assessing these key areas at the 2-month post-transmetatarsal amputation visit, clinicians can identify complications early, implement appropriate interventions, and optimize functional outcomes for patients.