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Herbert E. Pedersen and A. Jackson Day
J Bone Joint Surg Am. 1954;36:1190-1218.

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Publisher Information         The Journal of Bone and Joint Surgery
                              20 Pickering Street, Needham, MA 02492-3157
                                                   THE               THANSMETATARSAL                                                             AMPUTATION                                         IN
                                                                  PEHIPHEHAL                                       VASCULAR                               DISEASE                         *j.

              BY          HERBERT                  K.     IEDERSEN,                       M.D.,           AND         A.      JACKSON                    DAY,           M.D.,          DETROIT,                 Mnc’HnGAN

                          Front        the      1)epartmnenl               of Surgery,               lI’ayne           I niversity                College            of Medicine,                 1)etroit,         and          the
                      1)ivision            of ()rthopaedic                 Surgery,               (‘ailed          States        Veterans               Administration                      Hospital,               I)earborn

      Since   1944                             McKittrick                     arid       his coworkers                              have   used the                             trannsmetatarsal                                amputations
in the t.reatmennt                               of carefully                        selected    patiensts                            w’ith gangrene                                limited      to                  toes.         Although
these              authors               have            demonstrated                             inn a significant                             number                   of cases                that          the             procedure                  is
generally                  successful,                    there        is still            much              debate              as to its               real          value.          It is apparent                             that          many
surgeons                   dealing              with         peripheral                     vascular                  disease               have           had           rio experience                        with              this       opera-
tion          amid         hesitate                to      try       it.         There             are        many               who            still         feel       that          ann amputation                                   above           or
below               the       knnee          is inndicated                    for         the       treatment                       of arteriosclerotic                                gangrene                     of     toes.          Others,
such           as Pratt   arid Samuels,                                           feel that                  the trannsmetatarsal    amputations                                                       has little    to offer,
since          it cars be Su(’cessfinl  only                                       inn those                patients   who cans be adequately                                                       managed       by limiting
therapy           to the involved     toes.
              At the Deariorni    Veterans                                                Hospital,                  since           1947           all amputations                               have          beens              performed
015       the          Orthopaedic                         Service.                 Those                patiennts                  with           complications                             of        peripheral                        vascular
disease                are         seers         by       1)0th            the       Surgical                  Peripheral-Vascular                                         Service                and          the             Orthopaedic
Service,                  arid       the        (‘ombinsed                   treatment                      program          is outlined.    We have beers using                                                                       the tranns-
metatarsal                        amputation                      simnee 1950 in the                                belief that,     as the medical    arid surgical                                                                  treatment
of peripheral                        vascular                    disease   improves,                                patients     live longer   amid all amputations                                                                        become
more               suc(’essful               ; moreover,                     we       believe                that           long-term                    function                 is a primary                           (‘omnsiderations.
It is our feelimng now that,      inn properly    selected                                                                           patients,                       the tramismetatarsal                                    ampintation
results  inn ann excellemnt finmnctiomninng extremity,                                                                              with     relief                   of symptoms,        annd                             that    it. often
prevents                   a more                clisal)limng              amputations                        at      a higher                   level.
              Inn peripheral                            vas(’ular                 disease,               gangrene                    results              either                from            sudden                   oc(’lusionn              of a
major                vessel,             or from                 a mil(l             precipitatiisg                         factor              ins gradually                       progressive                          peripheral                    inn-
sufficiemncy.                      The          (‘ommorn               precipitating                           factors               are        exposure                   to      heat,           (‘old,           or         trauma,            amid
innfectioni                  following                   trimminng                   of         cornss          or      nails,             or      epidermophytosis.                                     We              are          (‘onn(’ernned
w’ith           this         se(’omnd            group             of patients.                       Inn that.               group              it is recognized                               that          the         patient               has          a
generalized                        (hsease               amid that,                  once           gamngrense                   develops                  inn onne toe,                    he is likely                         to      have          re-
peated                episodes,                  ivith       imnvolvemenit                          of      1)0th           feet,          amid with                   frequent                 periods                  of hospitaliza-
tionn.             Gamngremne                ann(l innfectionn h)egimnnnimig inn the toes is frequently    progressive,          spreading       to
the dorsinm     (If                        the foot or along      the plamntar    aspect of the foot. amid finally      requiring        a major
      For these     reasons    it appears                                                    that,   inn properly                                selected    patients                            with gangrenne                            limited
to toes,   removal      of all the toes                                                    is inndi(’ated     both                              as treatment          for                       the presemnting                            disease
amnd          as      a prophylactic                         measure.
              We           have              now         performed          tw’ensty-three                                          trannsmetatarsal                          amputations                                  for gangrene
with            results              which              parallel      those    of McKittrick                                              ansd his                   associates.       On                     the           basis of that
experiennce                       we         w’oinld          like           to      discuss                 the        proper                  selection                 of      patiennts,                  the              preoperative
preparations,       the operative                                        te(’hrnique,                        arsd the postoperative                                              care,          w’ith a few additional
remarks       omn the rationale                                        of treatment.                           It is hoped   that   there                                          will         be a more   widespread
use        of this                operation.
          *    Read          at     tine       Anmiual           M(’etimig           of     The          American                Academy                 of Orthopaedic                      Surgeons,                   Chicago,            llhinnois,
January       25, 1954.
        t Reviewed        inn tine                      Veteramns     Adnniniistration                                and           published                 with       the       approval       of                the Chief               Medical
Director.      The  statemennts                           amid roniclusionis        published                               by       the authors                 are     the      result    of their                ownn study               amid do
not       necessarily                reflect          the opinnion or policy of the                                    Veterans                 Adnninistration.

1 190                                                                                                                                                   THE      JOITRXAL              OF       BONE          ANI)         JOINT          SURGERY
                                                 TIIAXSMETAT.#{149}iRSAL                                    AMPUTATION                                   IN      PERIPHERAL                                VAS(’ULAR                       DISEASE                                 1191

                A(’(’or(limlg                           to McKittrick                                    amid his                    coworkers,                         the                operation                        is indicated                     for       gangrene
(If      all,         or          a part,                    of       one           or more                     toes,               providing                        the          gangrene                           amid imnfeetioni                       are       stah)ilized
annd            (10        riot                 imnvolve                   the        dorsal                or         plamntar                     surfaces                      of the                  foot.              They               also        include             those
Pnntiemits                      \Vii()            have     stabilized      opens                                    innfectionns      inn the distal                                                    portions              of the              foot,         if the entire
lesionn            (‘ann l)                      ex(’ise(l     arid primary                                        (‘losinre     (‘an be obtained.                                                       They               emphasize                      that     it is diffi-
(‘mnlt to (leterniinne                                          tine         possii)ihity                    of success                            inn a foot.                   with              deficient                  (‘ircinlations                    on     any       basis
other’             than                  (‘limni(’al                 judgment.                       Ins general,                             the         poorer                 the             circulatory                        arid         nnutritionnal                 status
of the                foot,               tine less                   (‘hann(’e               there              is of success.    However,                                                       the          absence            of palpable                          pulsation
i)elO\V                 tine             iliac             on        femoral                   artery               is rio comntra-imndicationn                                                           to      this         operation.                        The       special
(hiagnnosti(’                            measures                          used            ins peripheral                                vascular                    disease                      have              beers          of rio          material                 benefit.
If       tine           skinn                 011       the           (lorsinm                 of the                  foot                  is warm                  arid                 has           good              nsutritioms,                  success              cans       1)e
expe(’te(l.                           Maniy                   patiennts                     fall         into                a i)orderlinne                           category                           annd         must             be         advised               that           the
1)ossih)ilities                               of       healing                    are         questionable.                                    However,                          there                  are          many            patients                   with           healed
tramnsmetatarsal                                         stumps                       who            preoperatively                                        had             rio         pulsations                          below            the           femoral              artery
ann(I           who               had               (‘001,            shinny,              thins          skins              on         the         don-sum                  of            the          foot.          Success   has                       riot l)eenn seen
inn (‘uses                      inn whsi(’ls                    thene              was             discoloratioms                              on         the         dorsum,                           except           for rednness                        from    innulam-
matory                     (‘hannges.
                The              preoperative                                  period               of preparation                                       is (‘onnsidered                            to         be      the         most           importannt                   factor
inn determinnimng                                      su(’(’ess.                  1)urimng                that                perio(l              of tw’o to three                                     weeks,    the patiennt is restricted
to i)e(l                 rest                 with              the          extremity                      flat              in bed,                arid with   the                                    head    of the bed elevated        a few
imn(’hes.                  It         is hoped                        that           this          rest           will            (lecrease                    the          cir(’ulatory                             requirement.,                         prevemnt              addi-
tionnal                 trauma,                            allow               the          control                    of          imnfectiomn,                      arid             prevennt                       the       extension                     of       gangrene.
Tranismetatarsal                                                amputations                          is indicated                                  for        those              patients                       whose               ganngrene                   is stabilized
ann(l mnot progressive.
                1)unimsg                        the         period                 of       preparations,                                the          control                    of        infection                       is ann important                            prol)lem.
Tine            presemn’e                           of infection                          should              be         assumed                         ins a!! patients,                                including                   those               who        have     1)eemn
(‘lassifie(l                      as            having                 “     dry          gangrene                       “        or ischaemic                              necrosis.                         It is always                        possible,              inn these
minmmified                                    toes,             to         demonnstrate                            that                 at      the           line          of        demarcation                              there              is a break                   ins the
skinn,            amnd                inn most                    cases              there            is a small                             amount                   of pus.                     In          these          patiennts,                   unless          suitable
l)recaintiOnns                                are          takenn,               imsfectiomn                is     imntroduced.                               Therefore,                           all         patients               are         givers          anntil)iotics,
amn(1 loose                           sterile               (lressimngs                     are       worm                   at all times.                           The              sterile                 dressings                are         removed                once           or
twice               (lailY                    for          a fifteenn-mimsinte                                   foot              bath             ins tepid                    w’ater                  to         which            some              white           soap            has
beemn             a(lde(l.                      The             foot             i)aths            are        use(1                to         promote                  drainage                           arid         to      allow              a gentle               (l(’l)ride-
memnt.                  inn the                    foot           bath,              mne(’roti(’                 tissue                 which              is sponntanseously                                         separatimsg                      (‘ann be         removed
iviths            forceps                        arid           scissors,                   l)ut         viai)le                  tissire             should                never                  i)e         touched.
                 Innfectiomn                          as        a major                    problem                     is usually                         found                  ins the                group               of diabetics                     with            arterio-
s(’lerosis.                        Ther’e                   may              be       gross               Sprea(linig            infections,      particularly      along                                                                   the tensdonn sheaths
 inn the                 I)lttmnttir                    aspe(’t                  of the              foot.,            reqnnirinng      amputation           of a toe or                                                                   a wide    incision  amid
(Iraimlage,                           ini(’lu(linng                      the         removal                      of          the            toe         amid         its         metatarsal.                               only            when             infection                 has
 i)eens           completely                                 (‘omntrolled                     annd           it is obvious                                that          there                    is nno progressions                               of ganigrenne,                      earn
 the        t ramnsmetatarsal                                              amputation                            be comnsidered.
                Several                         important                         points             in the                   operative                       technnique                          must               he considered.                          The        amputa-
 tions           level                is just                   proximal                      to      the           metatarsal                             heads,                     so         that           at     the          conclusion                       of the          am-
 pnntationn, for all pra(’tical purposes,                                                                               there is onn!y borne between      dorsal                                                                                amid plantar    layers
 of       skin                annd               subcutaneous                                 tissue.                  A more   proximal    level  w-ould    pass                                                                                through     the (leep
 strln(’tures                            of         the           foot,            including                      relatively                             ischaemic                          muscle.                   The           dorsal                inncisionn           begins
 mid-way                          betweemn                         the         dorsal               arid           plamntar                    surfaces                     on         either                 side,          arid          w’ith          one        sharp           innci-
 sioms downn                             to         i)omne           it is (‘onnt.inmned                           inn a straight                               lime         across                     the          don-sum               to      the       mi(I-poirnt                 omn
 the opposite  side. This   is at the level of borne amputatiomn,  rio dorsal flap being formed.
 The planntar inncisionibegins at.either erichof the dorsal incision arid parallels the proximal
 flexionn (‘n-easeof the toes, but n-urnsone (‘emntimeter proximally to the flexioni (‘rease. This
 incision likewise must 1)e sharp ann(l (lirectly downs to l)omne. The lorng plantar flap thins

 ‘OI..          36-A.           NO.        6.       I)E(EMIIER                     1954
1192                                                                                                    in.     i:.        PEDERSEN                   AND        A.       J.     DAY

                                                                                                                                            obtaimne(l                  is dissected                             i)a(’k          to      tine           level          of      i)onne
                                                                                                                                            amputation.                              The               met.atar’sal                     heads,                  begiminiimsg
                                                                                                                                            w.i t.h the                 fi n-st. are  ,                  them             remove(I                       with              a saw.
                                                                                                                                            ihe          saw            l)lade                 is allowed                        to       rest            againnst                  the
                                                                                                                                            previously                         (ut             metatarsal,                            which                serves              as           a
                                                                                                                                            guide,            so that                      ann even                     stump                  is for’me(l.                     The
                                                                                                                                            p!anstar                  tenndomns                     amid              sesamoids                         nine       thnemn             n-c-
                                                                                                                                            moved                at       the             1)Onie             level.           The             (‘losure                is     made
                                                                                                                                            preferably                         inn omne layer                              with               mom-absorbable
                                                                                                                                            suture.               As           atraumatic                             a te(’hmni(lue                        as        possil)le
                                                                                                                                            is       mandatory.                                At            mo         tinie            shomnld                   tine skim
                                                                                                                                            margins                     1)e           tOin(’hed                        with              Ior(’eps.                    ‘l’issues
                                                                                                                                            should               be       handled                        lightly                with           tine         hmngen’s               arid
                                                                                                                                            a moist     gauze       sponge.    Also,   the closure   shoul(l
                                                                                                                                            be meticmnloins,          leavinng    nno dog-ears,    as tinese
                                                                                                                                            ill   slough      (lint. A large       bulky (lressimng is ap-
                                                                                                                                            plied           to the               nihole                  foot          amsd ankle,                         with             genntle
                                                                                                                                            pressure.                     Sinnce                  these                feet            will   nnot    tolerate
                                                                                                                                            much             pressure,                         the           skim         over           tine malleoli       amid
                                                                                                                                            the          i)ase            of          the              fifth            metatarsal                              shoinld               1)e
                                                                                                                                            carefully                   pa(lde(1,                        ann(1 adhesive                                  tape              should
                                                                                                                                            meyer            be         placed                   (hire(’tly                on          tine        skim.
                                                                                                                                                         After     operatiomn     the   patients                                                                return                 to
                                                                                                                                            strict            IXXI rest,    witin   the   head                                                            of       tine            bed
                                                                                                                                            slightly               elevated.                            At        least           half             of      the         sutures
                                                                                                                                            should                remains                      inn place                  for         two           weeks.                   Biner-
                                                                                                                                            gen’s            exercises                           are           hegunn                 tern          (lays              to          two
                                                                                                                                            weeks                 after                   operatiomn,                           inn      PreParat                     ion             for
                                                    lit;.           n-.                                                                     aml)ulationn                             at          three                 w-eeks;                 by           that              time,
       .    IILtI(, SIX t yft aim vians                                  (11(1, wi tin ant mmii )H’l(IO-                                    healing               is insually                          complete                       if it took     pla(’e by
sis.                     of
           ( :tlngn(’nn( I hit first.                             I OP  11:01              (l(V(lOI)((l                 StihI5P-
(fliPInt       to      tine      tminnnnninng               of     a (:LllUs.                                                               primary                   intention.                          The             patient.           at first     walks
                                                                                                                                            w-ith           loose              slippers                   until            all swellinng                           has         gomne
                                                                                                                                            arid          then             wears                    his           usual               shoes.                The              toe          is
 stuffed                wit.ln           \V(.)(Ii       01’         (‘ot         torn         annd             a t.ininn piece                    of     spring                 steel               is placed                     hetweenn                      the         layers
 of the             s(Il(’.       S(IIIie           l)tt          iemnl s isae                          l)refen’red                   to    remove                the           spring                  steel.            The           finna!           gait         is     excel-

 lent.         at      a ni(I(Iem’atc                         walk,                 lInt            a    linip              ai)ears               with           imi(’reasimng                         rates            of movement.
               I)efon’niit                  ies     fronss                 unnbalannced                               nilns(imlatimme                    (10 mnot (le\’elOp                                      inn I lie            stumps,                     annd         they
 iill        stamn(l             imp \\Pll                  immalem’ inse.                          \Vhile                  nie     have             adequate                    follow-up                            studies                 on         tine       series             to
 1)e n’el)(In’te(I                      here,         I he             figures                 of        \I(’littmi(’k                      amid his assO(’iates                                          are           mome             sigrnifiranit.                       They
 repol’te(I                   urn si gn’Oin)                      Of       (hiai)etic                    I)atiemnts                 followed                for as lonng as fifty-sevems                                                      months.                      Of 146
 J)at iemit            5      Whi(I         left        t he          hospit  0.1 with    healed     stumps,        ulcerations                                                                         re(’inrre(l       inn only                                    twemnty-
 fosnr,           or       1 6 per            (‘emnt        . ,    ann(l only    six of these    had    ampintatiomn          at                                                                    a higher        level. They                                    reported
 that,            of 202                patients                   followed,                            135,           or     67      per        (‘emit.,         had            satisfactory                             results;                 thirty-two,                         or
  16 per               (‘emit., mad                 unsatisfactory                                            resirlts          (they      were                  ambulatory,                                  hint      with incomplete                                        heal-
 inig        or        n’ecum’remnce                    of          inh’em’ationn)                            ; amid          thirty-five,                   or         17           per          cent.,               had failmnres    (with                                   pro-
 gressive                     diffmculty                arid               ansnputatiomn                              at      a higher                 level).
       [sing  the te(’hmnique (Ies(’n’ibed, we have    performed   twenty-three    amputations   on
 twemnty-onne patiemnts withn I)eriPlser’alvascinlan- disease. Of these, thin-cewere for thrombo-
 amngiitis                 ohlitem’amns,                          five            for’         arteriosclerosis,                                 arid        fifteens                     were            for           diabetes with art.erio-
 s(’lerosis.                   Wit         in onie                except                  ionn,         all           had          gangrene                 limited                       to      omne or                m(lre  toes, associated
 with             mild            ((I      moderate                              l(I(al           (‘ellulitis.                     The       exceptions                        was             a diabetit’                       patient                   with             a pen--
 sistennt              inleer            inn a first                     t(Ie,            associated                         with severe n’estpaimn.

                                                                                                                                                                       linE          J(IURNAL                   OF      13(INE          ANI)            JOINT          SUR(1RY
                                                   Tnt.xSMF:’r.i’rAntSAn                                              .MPu’rATnox                          mx PERPHEHAL                                        v.S(’uLAnt                      DmSF:.sF:                                         1193


                                                                       F’n;.         1-B                                                                                                                                 Fiu.           I-C
            l’ig.           I -B : Two                       \((ks               after            t.rannsnnnetatarsal                   aninputat               ion, vit.hout       synipathectonnv,       t here was                                                            hlrinniarY
        hn(a linng.           ‘The             (   liS(’Oli)Iat              1011         (III       t lie dorsunn                   of t lie foot               o(’(’urs  freqtnennt    ly :und inn sonise cases    I                                                         PP0I1IPS             It
        nn(PI’otic            slough.
           l’ig.            1 -(.‘ : I healing                        :ts           l.nnn(vennt               ftnl.      timid      tint      p:mt iennt        is asvnnl)tonnat                               P   :   him is      at     work         as        :t     ino6’l           (1(1k.

             Figint                     I)atienits                    iitt(l             1)r’iniam’y’                   healing;                  nninne had                 se(’onndan’y                          hsealimng             ; foinr’        still              have               snsahl
gn’amnmnlatinng                              areas                  whiichs              are            exl)e(’ted                   to       hneal : arid                  t\V(l              had           gross         failures.                 Fhe                two           failimres
were             time                  t0          progressive                                   gangrene                         beginnnnimng                 at       tine                   ampintationn                        site        ; t hney                 occmnrred                        ins

Patiemnts                Who were       knnowmn                                                   t(I   hiave     sim(’h                     (lxtemnSive    disease                                     that            smmc’ess               was          most                 innnlikelv.
These               l)stt iemnts finally     had                                                   r’eanipintationn                             ah)ove   the kmnee.
             It        is        believed                            inowever,                           t mat          ,   nso      rnat t en’ yhat                          (‘mit en-ia are                           imse(1 for               selem’t i nig l)ttt iennt                               s,

t her’e          \i 11 st ill be sonic                                            faihinmes.                      )iloreover,                      it is proh)ai)ly                                  t r’ine thsat                unnless            t here              is a (ert                 ai mm
pen’enitage                              of            failure                   inn any                      series,               riot          enough               tr’annsnsetatan’sal                                        ampintatiomns                                are             h)eimng
(Ionic.            Fhe                 I)atiemit                    amn(l his                     relatives                   slnoinld              be     aclvise(l                   that                 failure              or       delave(1                     healinng                   is a
defimnite                   possibility                               annd,               unless                   1)0th            tue           1)atiemnt            annd                tine             physician                    are       1)r’epare(l                          to       deal
ivitin          these                   ((Impli(’ationns,                                        tine         operation                       shiomnld              never                  l)e        atteflil)ted.
             line             t                    niiost             ((Imsinsomn                       (‘auses               of      (lelave(l                healinng                        are      marginnal                       mne(m’osis            of t lie                  \v(Iumn(1
e(lges             amid                vomnnnd                      innfeetionm.                        \\e           inn(’lu(le              vithn           marginnal                          mne(’r’osis              t inc slomngisinng                             of       (log-can’s
lund        extennsi(Imn                               (If     ganngr’emie                             I 0 t inc (lOr’smnfli                         (If      the           foot           .     \Vithn                womnmnd            innfeet        ion             we             inn(’lmn(le
ni i nnon’ st i t cli                          ai s’esses                           a mid gross                          nvou mid i nnfeet                     ion      .      \.      d        is(ussiomn                 (If         t hiese       eoml)l                   i (‘nit    1(    )nns is
of      import                annee,                   be(’ainse                    t hey                o(’(’ur            frequemntlv                       amid          because,                          if they             are          mnot misamnaged                                l)m’p-
cmlv,           tine          pen’(’emntage                                 of       failure                 inn(’n’eases sharply. Inn the is(’liaensi(’      extremity   the halann(’e
hetweemn                     tine             available                           1)100(1                smnpply anal tine riced fom’ nimrtritiomn       is so fine tinat tinny \vomnnn(1
(‘omph(’at                       ionn is likely to tip                                                   tine 1)alamn(’e t owam’d ganngn’emie. Amy inn(’isiomn will imn(’m’ease tine
demand                       for             1)10(1(1.                The                 womnmnd                     (‘ompli(’atiomns,                             then’efor-e,                            shoirld              lIe      treated                     inn       the            same
fashionn                in vhnieh                             the           foot                 was          pr’epared                     for’ surgery,                           that              is,      with         antibiotics,                              sterile                 (lress-
inngs.          amid                   daily                 I epi(l              soaks,                      alhowinng                    for’      (lm’aimnage,                      sponntanneomms                              separat             ion               (II       mie(’n’ot Ic
mat en’ial,                       amid               isealimng                     by             gr’amnulat                 ionn          t issmne.           We             feel               t isat            smnn’gi(’al                rensoval                   of          escinars,
se(’(Ini(larv                          (‘ImIsmnres,                    amid              skinn-gn’aftinng                            sin(Imrld             i)e aVOi(le(1.

Vol..      36-A,            Nm    (.    6,     I )L(         i:M      OER           1954
1194                                                                                                                      II.      E.     n’En)ErISEN                          AND         A. J.       DAY

                                                                      l’no.         2-.                                                                                                                                      Fo;.       2-B

                 I’ig.         2-.             : .fOr     lunahan                       5\nnnl)athl((t()Iin\,                                    t     tn:tnisniitt:tt:tnsal                    Lnlil)Utatioln               as         1)(lfOlnii(1l.              l1(alinlg                   :ts
        ((     )Iin})lj(’(               I(     I I )V :1 st it (in                 (1(5(155.

                 lig.          2- l : I haling                          IL5             i       inn,         )l(te      t iim((         ninont          his aft en ol)(n’IttiOIi.

                      \largimitl                         \Volnnnd                  rne(n’osis                          ann(1 miso(lerate                                  extension                 of gamngremne                       (I(’(’mnn’re(I              severn                     times;
inn          (Ili(.          (If         t iiese          ,a-es               t ins                    \\tns          (line        to      I inc             slough             of a dog-ear.                            Of these,                  four        Pat annt s isave
oh)tainne(l                              S(1)ttm’ttt            i(Inn         of            t    ha             (S(’httn’              annd            final             healing,               amid       tinn’ee            inave              small,         (‘learn,                  gm’amnim-
hit 1mg areas                                     of less                tisani                   (Ili               sqmnar’e             (‘enitimeten,                          nvhich            ar’e          exl)ecte(l                 to         meal.        line            timne               m’e-
(hmnin’e(l                    to          Il(hni(Ve                  lseahinng                           is of great                       inipon’tamn(’e.                           Fhe         foinm’ stumps                         \vini(’is           hneale(l did so inn
t    hnn’ee, three                               arntl          a half,                         t velve,         ann(1                    fifteen                   months.                 Inn tine thin-ce stumps                                      riot (limit e hneale(1,
t     inc         i mnt em’VILI                   Si ll(’e              )I)em’a t n an vas                                      mi na,               fift        cern     ,   amid     sixteen               misomnt          ins      at        t he      t ime           of’      m’it              imng.

    I I (I\V(’s’e1’.                          al I of t hiese                      1)111 i(’nits                       \\(‘re           amhnnlatom’v                            oh     (‘nint(’lnes,                 hegimnmnimng                   al)(nnt          I   \()         nnomnthns
aft en’ open’at                                  ionn,         ivhiemn              I inc                 es(’han’               separated                              amn(1 gramninlatiomns                            appeared.
                      lIst           (    )J)en’at         I   \‘e       irnfecl                   i( )li            o(’(’mnn’n’e( I I nn six                            pat    iennts.            1\v(      )     1)1st iemits             into        1 smnall               si   It cli            ah-
S(’(SS(s.                       Fathn       )f t hnese
                                                     (         r i ned  t h nec nin(.)mnt hs I )ef( In-c (‘omplet
                                                                                     l’((                1             e heali nig      nmndem’ I inc n’egi memn                                                                                   i

(    lescri                I I( I I nt )ve.
                                          t      I rn f,mn m’1)itt iemnt s t hnen vas gross          i mnfect i( I i of t Inc em nt i me sinm i( I ‘Fin        of                                                                                                              .

      inese                were     (hiallet    irs wit In infected          mne(’rOtic   toes who had i)eemn operated                  inpomn ivinemi it was
fell              I mat              I lie inifectionn                               was                       adeqmnately                            (‘onstrolled.                   At         the       time             of open-tnt                  ionn inn one                          it was
ollviolls                          t hat I here        w                                        s anie                ext emnsiomi                          of      infect       ionn along                      t lie     flexor’            tenndonn              sheaf                is.      This
was                   probably                           tn-ne          inn t inc                        (It    hem’s           also.         The                  fourt        Ii patient                wit Ii gm’oss                     woinnn(1            inntem’t             ion              had
Bnrer’gen”s                                   (hisease           :   i)e(’amns(’                               of his           ex(’r’mm(’iatimng                          paint,          he     had            beemn        operated                     mnponi    bef one                           the
inn feet ion                             was         completely                                        (omit          mol led.             Inn these                       fomrr       patients                   all      sut un’es               \(r’e        r’emni( Iveol                     ;    tine
    flap              as                 (‘ominplet              clv           freed                           : amid            the          voumid                      was        thorouginly                          irrigated.                    They             were                   again
I n’eated with                                     dail              soaks                      :111(1 sterile                          olressimsgs,                       wit in sinitable                      anni ibiotics.                    Withomnt                    inlolit           ionnal
smnn’ger’yeacin                                      (If       tinese               wonnnnds healed                                                                       four’, live,
                                                                                                                                                 irnnevemitfully innfomnm’,                                                                        ann.!       sevenn nniomnthis,

                                                                                                                                                                                            l’Ill       JO(IONAI.                 01    nOINI;          AND     JOINT                SmIGI;ltY
                                                        ‘rrt.xsMm:’m’.’n’.ntS.\m.                                            .#{149}Mn’m’m’.TnoNmx ERIIIERAL                                                                   \‘.SrUL.m                                DISE.\I4F:                                      119.5

                                                                        i:,.                             :‘

                                                                                                                                                                                                                                         11(1.                  -l

                                                                                                                                                                                        l’ig.           3-.\. : .\ft r               t n’ItlnsniUt                      atarsal                a 1111 )trt ;tt 1(111,
                                                                                                                                                                            I lane                :ts         It l’(I55           vouIn(l       ah                   i5(’t55.

                                                                                                                                                                                                        3-B       : \\‘it
                                                                                                                                                                                                                              vi t hn
                                                                                                                                                                                                                                                                       t ionnal
                                                                                                                                                                                                                                                                                  nest       ,amid
                                                                          I’u;.             3-A                                                                                 i nig      \:ts           (‘()mill)h(t         e inn fiv(’                  niionitii.

n’esl)(’(’t            I \(lV.                          ‘Fine           filth)              was               pmnlied               up          over           t he              h)onne                 ennd           ily      gramninlat                           iomn tissmre,                        and          goo(l
fmnnnct          i(Innai                     st        mnnips             m’esmnlt ed                     .     \\‘hienn            I nnfert            iomn          is        t lie           pn’iman’y                      l)m’oblem                        ,    it (‘ann             be        hamn(lled                      if
(ln’airnage                         iS        l1(le(lmlat                     (.       ‘l’hnis            exper’ienn(’e                         is similar’                       to that                     n’el)onte(l                 ls’              }mnn’ste                ann(l          I I(’r’r’mannnn.
                 Inn           I   me (‘onnsi(len’ationn                                                 of        sl)ecific                    fta’ton’s                  \yhii(’hn                    conntr’ihmnte                         to            success                      on’ f’tniimmn’e, ann
lot 1(1551)1                       \\115               nnsmul(’           to          (‘OI’I’elltte                     1)tihl)ttiIl(               pinlsati(Inn                           inn tine               ext        r’emity                 annd                1 he          r’ate       (If       healinng.

( )mnlv            t   mmcc                       1)atienits                         liti(I1)ahl)able                                J)mnlsatiomns                          inn the                       foot.              ( )f tinese,                            one           hsad           isealinng                  i’
lIn’imisan’Y inntemnti(Inn,    inn (Ili                                                                 theme                as          man’ginnal                      miecm’osis     vitii                                  eventual                              hsealinng                 inn I hm’ee arid
It  Iittlf nin Ill t his, amid i nn one                                                                 t mere               \as         a small                      st it (‘in ah)s(’ess                                   \vhsi(’in             \\.ISS             fimnalls’              (‘omit   m’olled inn
I mmcc             ninonil                    his.         ( )f          five               1)atiemnts                    vhose                  m(Ist                per’iI)hnen’al                            l)all)ai)le                      pmmhse                                  the              1)(Il)lit(’fll,
I hi nec          hna I hneali nig by                                                 mn’i man’s’                      I mn err t i Inn , omne had
                                                                                                                          t                                                               a st I t ch al)s(’ess                                    iyhich                       ivas         (‘omnt n’olled                    inn
I mmcc            nnonnt ins, ann(1 onne had                                                                   a gn’oss \vomnmn(1 ai)scess vith                                                                 isealinng inn fomnr nionnths.                                                             ()f fifteen
1)111 ienits vhnose niost J)enipii(n’al l)alptni)le J)irlse                                                                                                                                  tine iliac on’ femom’al, foinm had                                                                                 healing
1)\’ l)m’iniian’Y intent i(Ili : innsix hsealinng was coniplete                                                                                                                           hut (lelaye(l; inntinree healing was                                                                                   inneom-
1)101 e a I I                       me t I misc                        (If’        \Vl’i        t lug h)mnl is expect     ((1 : amn(l t \I                                                                had           gr’oss            failinn’es.                           ‘Thins           I hne faihmnres
ILnn(1 tinoso                                vitis               mlnn(Imnlv                       j)n’olonnged  isealinng     an’e inn tine                                                               gm’oimp               ivithi              11(1             pinlsationn                    hlelO\V                 tine
fenion’;nl                     an’tem’v.                         \\‘hile                   it     is          oi)vi(Imrslv                  true              tinat              tine             1)(Ion’en’             the           (‘iro’inlati(Imm,                               the        less           chamice
I here            is of’ healing,                                                                (
                                                                          smn’’ess (II’ f’ailmnm’e‘animnot lIe (let(’n’mimned                                                                                                oni the 1111515
                                                                                                                                                                                                                                           of’l)all)able 1)mnlsa-
II      )l I .         I l I I t ri k
                           ‘                              ( ‘          Ill I (      1 inI s            n.55(      )(   ‘I a t es         em phiasi                    ZC(        I I      inn t t here                        a r’e fn’e                    i   rem nt si nm’pn’ises                            i nn    1 lot ii
(    Ii n’e(’t Ii )l           15.           “mn(’(’(’55                   or’ 110 hmr’e is                             pn’(Ii)ailly                    (let en’nnimne(l                                I IY t lie            extent                 (If             (‘(111111 en’al ci r’cmnlat loIn
\VIni(’hs              In(s              (   1e\elope                          I am n(h t here                          is        11(1 tu’cept                (NI met                     hod             of olet em’mi ni rig t hint                                              (‘Ollat            en-al        ci    rein-
hat ion                except                           the            purely                     m’hinnical.                     None            of      the              objective                            methods                          has been                           so successful                              as
I nnspe(’t i(Inn (If                                     tine            leg               fon’        t he            colon’            arid            mint r’itiomn (If                                the           skin             ann(l                  subcmntanneous                                  t issimes,
h)snlpat            loin loIn- wan’mths,                                                         ann(l (‘himni(’alexpem’iennce.
                 Alt In mrgii little  vork                                                         has  been   donne   on the pr(Il)lem,                                                                                 t hen’e           is        S(IfliC                    expen’imenit                      al      cvi-
(Ienn(’e               a mid nsu(’hs                                   (li nn1(151                     (V1(       hence              that               the           t n’annsmet                         at am’sal               amput                         at ionn             takes                 gm’eat            15(1-
vann   age of the
            t                                                   (‘01 hat en’al                     ci rein kt                 ion         tns      it     develops                                inn the               leg.          I mnject e(l                        specimemis,                           smn(’in
\V(’i’e ill inst mated                                            by               \ I ‘ Kit I r’ick                         amid         Root,                as well                          as       some                of omnn                o\vmn,suggest                                     t   mat          t mere
are          areas                   vhien’e                      (‘011151                 en’al(‘in’o’tnlat ionr develops                                                        wit in ease                           annd           of lien’s                      whnen’e             it is ‘irt                    irally
inlpossillle.                                     It      is felt                    tisat              there                are         few,            if anny,                       (‘ollateral vessels inn tine                                                             toes,           tine           (Ion-simm

V( )l...16-A, Nfl.                                6, I)I;(l;MI(l;no 1954
1196                                                                                                   ii.       E.       PEDEESEN                        AND         A.     J.    DAY

                                                           1’n(;. 4-A                                                                                                                            Fnu.       4-B
             I’ig.      4-.\. :                 (IiILi)(’ti(’.            i’ean’s old, tre:tt.e(I
                                                                         sixty-I          win          for gangrene     of the first toe. There          was no lIUls(’ hIP-
       lov I hit feninoral,                          amid thn(skinn 011 tine dorsumin        of the foot was (‘001, shinny,       ItniCi atrophic.       Two      weeks   after
       t I’annsmn(’tatarsal                         aflnl)UtatiOli I here   \IL5  niarginnal      miecrosis   annd discolorationn      of the     medial     1x)rtiomi  of tue
     J)lannt8          n’    flap.
             F’ig.      4-11 : \\‘it               in t’onnsi’ry:ttivi                       t:ore       tint         l)ati(’nnt           h)e(’anse            aninhlulamit         early,         but     conuplete           hnealinng         m’e(nuire(l
     fifteenn           mnnonnthns                of tneatnnnennt.

of      I   Inc      foot       ,     Itnn(l         along               t Inc annt en-ion’ aspe(’t                                      (If     the      leg.       ( )mi the          other             hannd,        there       may            be many
lime          collaten’al                          vessels                   inn thne            planntar                    sinbcutanneoins                           tissue.            When              postoperative                         ganngremse
is     seem            after’               anspintationns                             for’          pen’iphseral                        vas(’ular                 (lisease,             it. is almost                  always          connfimned                  to
t iie (lomsinm                            of the               foot          inn I lie          tramismetatarsal                                        ampint.ationns                   arid        amputatiorns                   of single                  toes,
amid to the                          annterolateral                                skin          flap           inn the                  h)e!ow-the-knsee                            ampimtationi.                   A great            part              of      the
5il(’(’(5S              (If         tine          tramnsmetatan’sal                                   amputations                                is (line to the                     misc of a long planntar    flap of skins
arid          smnl)cimt.anieomns                                 tissmne            wit hnout                   a (lOr’sal                     flap.       Likewise,                  the amptmtatiomn   is pen-formed    far
ennoirghs               distally                         5(1      that         tine          (leep              stn’tn(’tures                      of     the       foot          are     mnot involved.
                If tine (Ievelopnsemlt                                             of t’olkntem’al                          (‘in’cinlationn                is of impon’tamnce,                              the n-ole of pn’eoper’ative
lunillan’                   synipat                 heo’toniy                       must              he         evalmnated.                           The   patients    inn this                           series  were seems hly the
Sinr’gical                    Pen’iphen’al                            \ascmrlan’                  Sen’vice,                        who           performed                     lirmbar              sympathectomy                           uponn              foinr-
teenn           of      the               t wenity-llnne                       pat          iennts.          Tine             results,                  inn that.           group,            parallel             those         inn the           gm’oinp          as
a    winole,                  Wit          ii     van’ial              ion         fr’onn        primary                           healing               to complete                     failure            amid early              high           amputa-
tionn.            ( )mne            (If         tinese            pat iemnt s, who                               had palpai)le pulsations inn the foot, still had marginal
nnecn’osis                    followinng                         his         ampmntationn,                         fimnalhealing i)einsg delayed three and a half months.
nn           I inc     othiem’                  hannd, anionng thiose for’ winom                                                                 sympathectomy                                was         felt to he of rio                      valine          was
a mani, sevemnty-hve                                                  year’s          old,           with             pipe-stem                         vessels            visible            inn roemntgensograms                          of the feet;
mis niost                     periplnem’al                        palpahlle                     pinlse           was               the         femoral             artery            ann(1 his wound                       healed           by primary
imitentionn,                        except                     for’      a small                 (log-ear                    which                 sloughed                  an-nd healed.

                                                                                                                                                                           ‘rnnn; J(I(RNAI.               0)1’ 1t(INE       AND      JOINT           si’nu;n:mnY
                                         TnLSxSMETATARS.SL                                      AMPITATI(IN                        mx      PERIPHERAL                      VAS(’ULAR                    DISEASE                                   1 197

            It is the               aimthors’                  belief             that         with          the       material               available                   inn this            study           we       cannot               evalu-
ate        the        role        played                by       hnmbar                   sympathectomy                                  in the         fimsal results.                        The       series             is too          small,
ann(I the                n’e(’ords              of the               respomnse                  to sympathectomy                                    are       too          inaccurate.                        A(’cordinng                to our’
(‘liniical            obsem’vationns                       in this                type          of patient,                  it did          nnot iniflinensce                        the      finnal out(’ome.                        Warn-ens
and         his          asso(’iates                    reporte(i                    similar                observationns.                        There             was,              however,                  rio        extension                     of
gangrene       which                             (‘Oimld be attributed                                       to lumbar                     sympathectomy.                                     Sinsce there   have     beers
iso complications                                 of sympathectomy,                                         amid there                   has i)eemn rio accurate                                  method   of preopera-
tively            evahirat               i mg t he             postoperati                      ye        responnse,               the      operations                    has         I)een       re(’ommennded                          when-
ever         it     was           felt         that        any              degree             of     respomsse               might               follow.            It         is possible               that             mansy            of      the
good              results                are          imn part                   (lime        to      increased                    peripheral                  1)100(1                 sinpply            followinng                   lumbar
            Sympathectomy                                       inn the              past            has         i)eemn m’ecommemn(led                               as         a meamns                 of      o’omntn’ollinng                   rest
pairn.   It              has been      well estai)lishe(l                                                 that       inn many     (‘ases                       of inntermittennt                           (‘latm(li(’atiomi    the
response                  is dramatic.     Inn thus series                                                 we      wen-e conncerned,                          however,       with                        pen-sistemnt      pains inn
the        toes          with            or without                         an     opens,            infected                lesion.          Inn five              of these                  patients                such       pails             n’as
a major                (‘omplainit                     arid       in rio case                      did      sympathectomy                              relieve              the         pains.         Omn the               other          hand,
all      five         were           completely                         relieved                   following                 tranismetatan-sal                         ampumtatioms                        whens the w’ounsd
was         completely                          healed.                Oine          of these                patients             had healing                        by primary                          inntenstioms arid w’as
relieved                 immediately.                         One had a noms-innfected                                                marginal                 necrosis     after                       operationi.                    He was
completely                   relieved                     until  the eschar separated,                                                 exposing                 granulating                           tissue.       His               pains n-c-
turned,                arid          disappeared                                 when
                                                                           finally       the wound           was completely                                                                        healed.     Two    of the
patients                with           Buerger’s                        diseasehad exquisite         pain    preoperatively,                                                                     as well as postopera-
tively             while            infection                    was  present.      They     likewise       were    relieved                                                                when       healing    n’as corn-
plete.             It. is believed                            that   pains inn these      patients        is due in large                                                                   part      to involvement        of
peripheral       nerves      by                               fibrosis              annd acute                     iniflammations.
        Inn many      patients                                   pairs            is so severe                     arid so persistent                           that              large          doses          of narcotics                        are
necessary                    arid         the          patients                   become                  severe            nursing               problems.                     Many             limbs           under               such          ci--
(‘umstannces               have   beers needlessly                                               sacrificed    at the                         patient’s               insistence.                       Pain   inn the toes                           at
the        site       of ams opens lesion    is not                                            an imsdicatioms    for                        a major                amputations.                         These    patients                           do
nnot beo’ome                       narcotic                   addicts.                   In        each          of the         cases             mentioned                       the         patiemnt           stopped                asking
for        relief when                     his lesiomn is-as healed.
             From   the                   corni)ined   experience                                          of those            who           have            used          the          tranismetatarsal                             ampimta-
tion        inn peripheral                            vascular                   disease             it is apparent                        that        it is possible                         in a high                percentage                        of
patients        to obtains     w-ell healed          stumps.         Ins any discussions           of the unse of this type of amputa-
tions    three    specific     criticisms        can be made.                The authors         feel that      these  criticisms      should    be
mentioned           arid discussed          briefly.
         First,    it is believed         by some         that       using      a (‘Oniservative         amputations       merely    (lelays   the
inevitable         amputations          at a higher           level.       In the presenit          series    there   were      only  three   late
complications.                             Ins one               patient.,                    fourteens              months                 after         complete                      healing,               gamsgremse                of the
enstire            leg       developed                        amid           a reamputatiomn                              ss’as          performed;                  ins onne pat iemst,                             one       year              after
complete                    healinng,             a small    superficial     infection    developed      which    was easily controlled;     amid
oise        patient              died            of coronary-artery          disease   three     monnths    after  complete  healing.    Ins the
follow-up                    study              of Mclcittrick        ansd his coworkers         only six of 146 patients had reamputa-
tioni       at a higher                         level.
            The second                          criticism is that                              many              of the        patiemnts             suitable                   for     tramnsmetatarsal                             amputa-
tion         riced           only              removal                 of the              innvolved                toes.          Yet,           if treatment                        is limited                to      the          innvolved
toes,         seven-al               months                    are          frequently                     requmired               for       complete                     healing.               After           this         treatment,
gangrene                    may           at      any           time             develop                 in the         remaining                    toes,          the          most          vulnerable                     part          of      the
extremity.                      Of the                twensty-omne                        patients                 inn this          series,           mine          had              had        one          or more                previous
hospital                 admissions                       for        the          treatment                      of gangrenous                       toes.          Ins such                  episodes                it may            isot. he
possible                 to pnevenit                     the         spread                of gangrene                      arid         infections            to the                 foot,       or,         therefore,                to pre-
vennt         a major                    amputations.

VOL.       36-A.       NO.      6. I)E(EMBER                         i954
     I 198                                                                                                    H.        E.      PEDERSEN                          AND              A.      J.     DAY

         The                  third   (‘n-iti(’ism iS that.   for some    patiensts too                                                                                                       long          a time                    is required                           for         delayed
 healing,                    resmmltimsg inn great      econsomic     loss amid delay                                                                                                      ins rehabilitation.                                              In       this             group                  of
 twenty-three                                 ampimtationss,                                  there                were              thin-teen                   instances                        of delayed                          heahinng,                    or 56 per                       cent.
 of the              t(Ital.                 Imi most                   cases                 the           patiemnts                    s’ere               ambulant                            and            might                 have              been              out-patients
 after              two          mornths.                       Inn this                 group                 only              five          stumps                       have                required                   longer                 thamn severn                           months
 to heal                  satisfactorily,                               ann(I in each                              of these                    there                was            some               reasons for feeling    that prolonged
 t.n-eatmennt                          was           jinstified.                        Onne            patient.                      a(’(’ounsted                          for          two           of the   five stumps.      He was ann
 elderly           diabetic    w’ith n-n) periphen’al      pulse  below- the femoral                                                                                                                              on either  side.  At different
 times           ganngrenne   of the first toe ins ea(’h foot developed.             On                                                                                                                         each side, when    demarcations
was            complete,    a t.ramnsmetatarsal       amputations     was performed.                                                                                                                             At the time of each amputa-
t.ionn he had                           rest             paimn, man’ked                                 atrophy                       of the                 leg,           arid          (‘001,           thins,            shinny               skins            on       the          (Ion-sum
 of each                  foot.           ()mne stump                              healed                 inn fifteen                       months                    and               the       other                was         almost                    healed                   at fifteens
 months.                     Inn many                        (‘linnics                  1)0th            extremities                              w’ould                   have               beers             treated                    by         ampuntation                              above
 the           kmnee.
                It is unnifortunnate                                      that                this          serious                    disease                  occurs                    primarily                        inn elderly                        people.                  There                    is
always                    bilateral                       inivolvemenst                                 annd,                inn the              evennt               of         bilateral                      high            amputations,                                     these                   pa-
tiemnts              do riot                  sinccessfumhly     wear    prostheses                                                                arid a wheel-chair                                             existence  results.
               It      is the                  atmthors’     impressions       that                                                         the       more widespread                                               use of the tramismetatarsal
amputations                               will            prolong                       the         productive                              lives              of many                          patients.
             NOTE:               The          authors                wish           to thamik                   Mr.           Earl          Bartlett,                 medicnnl                  photographer                          at      Dearborn                    Veterans                    Hos-

pitlil,           who        took             the photographs                                 used            to illustrate                       this         paper.


 1.       FURSTE,                WESLEY,                    and         HERRMANN,                              L. G. : Value                        of Trannsmetatarsal                                     Amputations                             in the           Management                              of
          Gangrense                 of Toes.                 Arcin.            Surg.,              57:         497-512,                     1948.
2.        MCKmTTRICK,                              IA. J. ; MCKI’r’rRncK,                                     J. B. ; and                     RISLEY,                 T.      S. : Transmetatarsal                                         Amputation                           for     Infection
          or Gangrene                        iii     Patiemsts                withn Diabetes                                 i\Iellitus.                Ann.          Surg.,              130:          826-842,                 1949.
3. McKI’rrRrCK,                                    L. J.,        arid         ROOT,                H.         F. : Diabetic                       Surgery.                   Philadelphia,                           Lea       & Febiger,                         1928.
4.        PRA1’r,            G.        H. : Surgical                         Management                              of Vascular                        Diseases,                  p. 72.             Philadelphia,                           Lea           & Febiger,                   1949.
5.        SAi1uEns,                 S. S. : iIanagemeInt                                      of Peripheral                          Arterial                Diseases,                   p. 230.            New-           York,              Oxford               University                      Press,
6.        WARREN,                      RICHARo;                    CRAWFORD,                             E.        S. ;        HARIY,                   I.      B.;         and          McKnrrRmcK,                             J.        B. : The                 Transmetatarsal
          Amputationi                        Hi     Arterial                 Deficielicy                      of the             Lower              Extremity.                          Surgery,                3 1: 132-140,                          1952.


             DR.          D0NAIn                   B. Sn.ocunn,                     luaENE,                    OREGON:                      Prior            to W’orld                  \Var          II it was              staisdard                  practice                to amputate
the        ganigrenous                    extremity                     of        the      patient                 with          peripheral                     vascular                  disease,              either           through                    the     necrotic                  portion
of a gamngrennous toe or ah)ove the supracomidylar                                                                                       level.               During   the past decade     amputations     below                                                                         the         knee
and through     the fore 1)art of the foot have beeni                                                                                    noted                with imicreasing  frequency.    Such presentationns                                                                                  as this
one         of Dr.              Pedersen                   amnd Dr.                Dliv’s             have              led      us      to       ask:          (1)        Why            this          trend          toward                 conservatism?                             (2)        Is the
transmetatarsal                               amputatiomi                         a good               procedure?                        (3)        What              are         the         indications                  for         this         amputation?
             The           trenid            toward               conservatism                              is based                   on         the         marked                reductions                    in       morbidity                        and          mortality                   after
amputation                        procedures.                       Three                factors               are           primarily                  responsible                      for       this.         First,          improvement                               in     anaesthetic
methods                   and          geriatric                care.         Seconsd,                  the          better            control                of infection                       because               of the              intelligent                   use          of rest             and
antibiotics,                     and         the         developmenit                         of      meticulous                       dressing                 techniques                       both        preoperatively                             amid        postoperatively.
Third,              the         fear         that          reamputation                              will          be        necessary                   because                  of infection                    and          spreadimig                        gangrene                has          been
diminished,                       since            the      latter            occurs               less         frequently,                       and          is more                  readily            controlled                      when             it does             occur.
             As to the seconid questiomi-Is                                                       metatarsal    amputation   a good procedure?-there          is little doubt                                                                                                                      that          a
well         healed,  painless amputatiomi                                                     stuml)    at the level of the metatarsal necks is satisfactory        for patients                                                                                                                     with
peripheral       vascular                                disease.                 Rapid               gait,             squatting,                  and           tiptoeing                     are        virtually                  lost,           but         moderate                    to      slow
gait    is good.     In the                               age       group             concerned,                          this last function     is all that is usually requin’ed.                                                                                  No prosthesis                               is
necessary                  annd only                 stuffinng               of     the   te   and                       occasionally    a spring steel in the sole of the shoe                                                                                    are      required.                     For
patients                  with           peripheral                     vascular                     disease,                  the       fact            that          transmetatarsal                                 amputation                            provides                  relatively
normal              gait         and         requires                no       prosthesis                      is of no               meani          importance                          and        is a definite                   advantage                        over         amputation
at        a higher               level,            since          the        in(’reased                     strain             imposed                   on      the         opposite                   extremity                     by        the         prosthetic                  gait          may
l)re(’ipitate                   gangrenne                  ins that               mensber.
            The            question                  of      indications                        for           transmetatarsal                                 amputation                          may           be        broken                dowmn              unto          two          further
                                                                                                                                                                                   THE            JOURNAL                  OF BONE                      AND          JOINT              SURGERY
                                                        TRANSMETATARSAL                                                                AMPUTATION                                      IN         PERIPHERAL                                 VASCULAR                              DISEASE                                              1199

(nU(’stiOlis     (1                     )     When   niay  trannsnsetatarsal                                                                       amputation                              be done?                  and          (2)      Should                it be carried                          out        iii l)refer(’In(’e
to annl)utationi                               of the toe?
              Transnnetatarsal                                                  anil)utationn                             is (‘olntra-indicated                                            when            gangrene                     is due             to      sudden                 major                 mtrterimtl             occlu-
sionn.          tmn(her                su(’h                   (‘ir(’unsstann(’(’s                                 the         extremity                        must                  be     amputated                         at        a level              conspatih)le                        with           tissue            Inealinig
and           tIne         use        of           tt         prosth(’sis.
              The            operatiomn                                   is iln(li(’Itted                           whenn                 gttmsgrene                     of         the         toes          is due               to      progressive                          PeriPheral                        insufficiency,
l)rovid(’(l                  that.                 tine           n’ogr’ss                        of gangrenie                                is stabilize(I                          to a point                        of demarcation,         infection                                       is controlled,       an(l
til(’      cir(’ulatiolnn                          of           thie skini                      onn the dorsunn                                 of tine foot                          is adequate.                        Since    the decision        for                                   amputationi       is based
011       (‘liIii(’al              ju(lgmenit                                  rathn(’r                  thani           upon               standard                       testing                 methods,                    the          procedure                       must             be         perfornne(1                    h)y ann
exl)eri(’n(’e(l                        clinniciami.
              TIne           answer                            to         tine             questiomn                  whether                       or        not          transmetatarsal                                   amputation                          should                 be        domie            in     preference
to      tOP         Itniputlitiomi                                  i5        nsore             difficult.                 The             authors                  say,             in effect,               that           involvement                         of a single                      toe      is the              precursor
(If furtiner                     ILIi(1 nnore                             extensive                         gamngrene                      and that                   it        is well            to carry                 out          amputation                         of the             fore        part           of tine            foot
Its II. h)rollhYllt(’tic                                       measure.                           Others                  feel         that.,            if the circulation                                   is adequate                         to support                       tue mirsimum                                metab)olic
n-equirenni(’nnts                            of           the                 tissues,                 as        well          as          tine      reactionnarv                           inflammation                             which                limits            the         extensioni                      of ganngrene
1111(1              the (‘ireulIttionn
              inif(’(’tioni,               will h)e adequate     to support    the trauma       of toe amputation.          It is my feeling
that iii linnited gangrene          of a single toe, when      amputation    may    be carried     out through      healthy      tissues,      such
as the nie(’k of the first or fifth metatarsal             or the proximal    phalanx     of the second,     third,   or fourth        toes, this
is the l)roo’e(lure   of choice. However,         if more than one toe is involved        or if a second toe amputation            is required,
transnsetatltrsal      ttmputationn     should be considered         on the basis of prophylaxis.

              DR             hARRY                             D.              MoRRrs,                       NEw                 ORLEANS,                           L0UI5nANA:                             I have               had             little          first-hand                    experiemice                       with           the
t(’(’hniiqime                     des(’rii)ed,                                  Prinn(’ipallY                         because                       transmetatarsal                                       amputations                            for       peripheral                        vascular                    disease              are
rarely               Performed                                 by              tinose             of us              who              do      the         majority                         of amputations                                 in our              area.          Another                    reason,                 however,
ITitt\’        well           h)( that,                         as Dr.                      Pe(lersen                      has         pointed                   out,            because                   ‘we have                 had          little         experience                        with          the        operation,
we         inesit;tte                  to              try           it.         We             all       agree                that           a successfully                                performed                        transmetathrsal                                amputation                             is superior                   to
other               low(’r-extremitv                                               annputations                                for          the       elderly,                   principally                        because                 it eliminates                          the         necessity                   for special
l)rosthseti(’                     devi(’es.                              In      additiomi,                       i)ecause                  of the              availai)ihity                        of antibiotics                          and          the         improved                medical                         and       surgi-
(‘ILl treat.nnennt                                 of          peripineral                               vascular                     disease,                  particularly                              adjunct                 sympathectomies,                                       amputations                            at      lower
levels               are         now                   much                    more                 feasible                   than               formerly.                     In         our       Clinic,               we        strongly                   believe                that           sympatheetomies
are         ni(It only                  helpful                               inn relieving                         the          symptoms                        of both                    vasospastic                       and           degenerative                           organic                disease                of blood
vess(’ls,                  with             or without                                     diabetes,                    but           also give                  a much                     better             prognosis                   in patients                      w-ith impending                                    gangrene.
              One             disadvantage                                             of        the         transsmetatarsal                                       technique,                       particularly                          in       private                 patients,                    is the                prolonged
p’riotl               of Preol)erative          preparation        and      the                                                                          relatively       long                            postoperative                         period                   of observation                                 necessitated
i)\’ the              frequent       developnnent           of complications.                                                                                   Moreover,                               the surgeon                        must      be               extremely        careful                            to perform
ali       annputation                                   at          a level                     which                will          ensure                as         far         as     possible                    that        amputations                             at        a higher                 level           will         not      i)e
mne(’essary                      hater.                 These                     disadvantages,                                      however,                      are         not         as great                 a consideration                               for       patients                   in public                    institu-
tionns,              for         whonn                        prolomnged                            hospitalization                                 is not                an         economic                      problem.
               In          sonne                  hands,                         the            percemitage                           of      successful                         results                  after           transmetatarsal                                amputations                               has          riot         beeni
nearly                115        high              mis thiltt                      reported                        h)y Dr.                  Pedersemi.                     Furste                 and         Herrmann                          in 1948               reixrted                   forty-one                     (habetics,
witin           satisfactory                                   results                inn 37 ler                          (‘(nt.           ; twenty-six                          patients                   with arteriosclerotic                                       gangrene,   with satisfactory
results               inn 3 1                                 (‘(nit.            ; ttnnd twelve                             patiemnts                    with             frostbite,                    with          satisfactory                        results          in 92 per (‘emit. However,
the early                        (‘11.5(5               iii         that              series                were           seen             ins 1934                 before                 the         advennt               of penicillin                        and           the         operlttionns                      were          per-
formed                     without                        primisary                         closure:                     tinis         undoubtedly                               ao’counts                    for         many             of       the         failures.
               I wish                 to re-enspinasize                                               the         poinnt              made               by      Dr.            Pedersen                      that          atraumatic                        handling                   of tissues,                    particularly
of      skim            flaps               lit         tise              tinnne            of amputations,                                   is paramounst.                                 Also,             determination                              of the             possih)ihty                        of a successful
result               of annputationi                                            Itt        ttIi%’         site        in         ann extremity                                 with          deficient                    circulation                     depends                     entirely                on         the       clinical
judgnscnnt                       of         tint              operator                          arid         special                  diagnostic                          measures                      are         of little             value.
               I ltIS5 sure                        tinat                  reports                   of      tinis         type              with          car#{128}fulfollow-up                                    studies               will       result            in nsuch                   wider             acceptance                       of
 this          l)ro(’(’dure,                            whni(’h                    inas          unnquestiomia.1)le                                 advamitages                             when              performed                     accordinng                      to     the           inndiclttions.

               I)R.           PEDER5EN                                        (closilng                   : ()nne              l)oilnt             I think                 is        sometimes                       overlooked-there                                        are         two            types            of      patiensts
witin           gaingrelne                             linnited                       to        toes.             ()nne          is     the          nian            who              has          just           had        a sudden                      occlusion                    of        a major                  vessel             and
wino,            after                conservative                                          ‘tre,              has          gangrene                          limited                  to         toes.            Every                time             we      hiave             done            a transmetatarsal
annputation                            iii         thnat                  type             of       patient,                   we          have           had         difficulty.                       Our          two          failures               annd many                      of the            cases            of     delayed
healing                    oc(’urred                           inn that                     type             of      patient.                      I do          not            claim              that this type of amputation                                                           is superior    to others,
lnut I would                            like                  to          poilnt             out. tinat                   it       is a       useful                procedure                       which has much to recommend                                                              it. Whether     or not
we         t’inoose               to do                       this             operationn                        inn preference                             to amputating                                   a single                toe         is a matter                      of      insdividual                      preference.
I think                    tinere                 are           nnanny                     reasonns                 for          saying               that            amputation                              of      the         toe       involved                     has     distinct disadvantages.
Most of the annputations        of sinngle toes depend                                                                                                               uponi             some kind                          of incision                    which               encroaches    on the dorsum
of the foot. The skin of the dorsum         is particularly                                                                                                                    vulnerable                      and          for that                   reason               there is a high incidence    of
delayed   healing iln patienits   who have amputation                                                                                                                          of a single                     toe.          My           personal                 feeling               is that                there            is a high
                                                                                                                                                  (Continued                          on         page          1218)

 VOL.           36-A,            NO.              6.          I)E(’EMI3ER                                1954
1218                                                                                                       J.      J.        FAHEY                   AND               J.     A.           BOLLINGER

 5,      BURMAN,                    M. :           Steniosing                           Tendovaginnitis                               of      Flexor              Poilicis                  Longus,                    Disability                         Other          Than            Trigger              Thumb.
         Bull.         Ilosp.               Joint                    Dis.,           6:          155-159,                    1945.
  6.     CAMEHER,                          J.           \\.      ,      unnd              SCHLEICHER,                               R. : Zur                    Atiologie                    des            “    schnellenden                                Fingers”.                    Mittt’ilunng                  von
         gleio’hzeitigem                                Vorkommemn                                 bei          eimseiigenn                 Zwillingen.                       Med.               Kim.,                 31 : 245-246,                              1935.
  7.     COMPEHE,                      l.           L.:              Bilateral                    Snapping                      Thumbs.                     Ann.              Surg.,              97:            773-777,                     1933.
  8.     lNeEn,,                  I). : Trigger                                 Finnge.r           Produced                         I))’ Excessive                          Heat.             Surgery,                       26:         659-664,                     1949.
  9.     FAn,K,              1’n)uARn):                        tiner              dt’un          so’hnellemnden                         Daumen                    bei             Kindern.                      Beitr.             z. Kim.                   Chir.,             153:       559-569,                 1931.
10.      GRAHAM,                     \\.          C. : Pt’rsoniai                                cornmunnio’ation.
1 1.     HARRENSTEIN,                                         H. J. : I)e                    “     Veerennde                        Vinger”                 h.ij jonige                     kinderenn.                      Nederlamndsch                              Tijdschr.                  v. Genneesk.,
         81:         1237-1241,                               1937.
1 2.     HAUCK,                   GUSTAV                       : Uber                   einne        Tenndovaginitis                                 stenosans                       der         Beugesehnenscheide                                                mit          dem         Phiinnonsen                  des
         schnnn(’llen)cien                      Fimngo’rs.                        Aro’h,            f. Klinn. Chir.,                          123: 233-258,     1923.
13.      HOWARII,                    L.         D., JR.                     ,    PRATT,               D.          H.     ,    and           BUNNELL,     STERLING:                                          The              Use         of Compound                               F (Hydrocortone)
         ins Oherative                             Itnn(l             Nonn-Operativo’                                   Connditions                        of     the             Hand.               J.         Bone               and            Joint            Surg.,               35-A:          994-1002,
         Oct.          1953.
14.      Ilunsox,                    H.          \\‘.          : Snapping                          Thunsb                     irs Childhood.                            Report                   of Eight                        Cases.               New             England                  J. Med.,               210:
         854-857,                   1934.
15.      JAIISS,                S. A.:             Trigger                        Finger              inn Children.                           J.     Am.              Med.             Assn.,               107:             1463-1464,                           1936.
16.      KRoH,                   FRITz:                   So’hnnelhennder                            Finger                    und           stenosierende                                 Tendovaginitis                                    der           Fingerbeugesehnne.                                 Arch.            f.
          Klinn, Chir.,                         136:            240-276,                          1925.
17.      LAn’nn)uS,                  P.         \V.:            St.ennosinsg                      Tonnovaginitis.                                 Surg.           Clin.              North              America,                         33:          1317-1347,                       1953.
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19.       Lnn’st’osmnt,                    P.           H. : Chromnio’                             Nonnspeo’ific                        Tenosynnovitis                                 amid           Peritendinitis.                                     Surg.           Clinn.         North             America,
         24:         780-797,                     1944.
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          1950.             Tine            Ansericann                             At’ntdernv                      of         Orthopaedic                          Surgeons,                          Vol.             VII,             pp.           254-261.                   Ann             Arbor,          J.      W.
         Edwar’ols,                  1950.
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                                                                                                                       TRANSMETATARSAL                                              Ann’uTATloN

                                                                                                                              (Continued                        from              page           1199)

ini(’idenno’e             (If     rt’l)entte(l                       innvolvennnennt                        in         pat.iennts                 who           have              gangrene                      limited                 to     toes.              There            is a specific                 reason
for      that:         If       a l)atienit                     htts             (‘xtennsive                    peripheral                    vascular                  disease                  and            if any             one         of his toes                      is ischaemic                   enough
SO)     that         a mild            fao’tor                   such               as a i)hster                        leads           to gangrene,                              then           I have                  good            reason                to believe                  that         the      rest         of
his      toes         are         inn a similar                                  state,            that.          a toe              is a part                   of         the        anatomy                         in        which               it     is practically                       impossible                   to
d(’velO1)             ani’         t’ohlateral                         circulation,                         and              that           the      circulation                           in all          toes             is    poor.
           On         the         sul)je(’t                    of          synspathectomy,                                      I likewise                      have              little         to        say.             Our          knowledge                         of      the      indications                   for
synnpatheo’tonsy                                is still                    based            erntirely                   on         clinical               impression.                        I realize                      that             this          is a very                  efficient              measure
for      the       care           of suo’in comnoiit.ions                                        Its inntermit.tennt                              claudication,                            but        I still               doubt              that           it is useful                 for      gangrenous

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