Open revascularization approach is associated with healing and ambulation after transmetatarsal amputation in patients with chronic limb threatening ischemia.

BACKGROUND: Transmetatarsal amputation (TMA) allows for maintenance of ambulatory function for patients with significant forefoot tissue loss. Effective revascularization is key to optimizing limb salvage for patients with chronic limb threatening ischemia (CLTI). We hypothesized that CLTI patients requiring TMA will have better healing and functional outcomes with open bypass than with endovascular revascularization. METHODS: Consecutive TMAs performed at three affiliated centers between 2008 and 2020 were retrospectively reviewed. The baseline characteristics, including WIfI (wound, ischemia, foot infection) stage, noninvasive vascular studies, healing, and ambulatory outcomes, were collected. Catheter-based angiographic images were evaluated using the GLASS (global limb anatomic staging system). The primary outcomes were TMA healing and community ambulation. The secondary outcomes were TMA that had healed at study end, any ambulatory function postoperatively, major amputation, and mortality. Descriptive statistics and univariate, multivariable, and Kaplan-Meier analyses were performed. RESULTS: A total of 346 TMAs had been performed in 318 patients, 209 of whom had had peripheral artery disease (PAD). The median follow-up was 2.5 years. Patients with PAD had had significantly lower rates of healing compared with those without PAD (64% vs 77%; P = .007). Revascularization was performed in 185 limbs, with 102 treated endovascularly and 83 with open surgery. The patients who had undergone endovascular surgery were significantly less likely to have had the TMA healed at any point (55% vs 76%; P = .003) and less likely to have remained healed at study end (49% vs 66%; P = .02). Patients with GLASS stage 3 anatomy were significantly more likely to have healed after open surgery (75% vs 45%; P = .003). Long-term ambulation data were available for 72% of the revascularized patients. Endovascular surgery was associated with a lower likelihood of community ambulation after TMA (34% vs 57%; P = .002). On multivariable analysis, open surgery was significantly associated with TMA healing (odds ratio, 2.8; P = .007) and ambulation (odds ratio, 2.9; P = .001). CONCLUSIONS: For patients with CLTI and significant tissue loss requiring TMA, an initial open approach to revascularization was associated with improved healing and higher rates of ambulation compared with endovascular interventions. The metabolic requirement for healing of a TMA in patients with CLTI might be better met by open revascularization.

Outcomes of Partial Calcanectomy in an Academic Limb Salvage Center: A Multicenter Review.

Chronic nonhealing heel ulcerations have been established as an independent risk factor for major amputation, with poor rates of limb salvage success. Partial calcanectomy is a controversial limb salvage procedure reserved for patients with these heel ulcerations. We conducted a retrospective cohort study reviewing 39 limbs that underwent a partial calcanectomy from 2012 to 2018 to evaluate the proportion of patients healed, time to healing, ulcer recurrence, and postoperative functional level compared to the preoperative state. In addition, age, gender, body mass index, smoking status, coronary artery disease, diabetes mellitus, renal insufficiency, dialysis, peripheral arterial disease, method of closure, and percent of calcaneus resected were evaluated. Mean follow-up for our cohort was 2.3 years. We had a 1 year mortality rate of 11%, and a major amputation rate of 18%. Our results demonstrated a 77% healing rate with a median time to healing of 162 days. We found that patients who were closed primarily had a faster time to healing compared to patients who underwent closure by secondary intention. Our data showed that ulcer recurrence developed in 57% of healed limbs. We found that 76% of our patients were ambulatory postoperatively. These results suggest that partial calcanectomy is a viable limb salvage procedure with a predictable level of ambulation and function in a high-risk patient population.

Desmoplastic Fibroblastoma (Collagenous Fibroma) of the Foot: A Case Report of a Rare Benign Tumor in an Atypical Patient.

Desmoplastic fibroblastoma (collagenous fibroma) is a rare benign soft-tissue tumor. Often found in the subcutaneous and muscle tissue, it is slowly enlarging and generally not painful or invasive. The literature often describes the tumor to be found in the upper extremities, neck, and back. Full excision of the tumor is the treatment of choice, and the prognosis is generally favorable; there are no documented cases of recurrence after full excision. We present an atypical case of desmoplastic fibroblastoma found on the dorsum of the foot with a larger tumor present in a substantially younger patient than is typical.

Bacteriologic analysis of bone biopsy from diabetic foot infections within a VA patient population.

Diabetic patients with foot infections were evaluated over a 5-year period from April 2005 to March 2010. Cultures were obtained from 92 patients after surgical debridement. All of the patients were classified as "severe" diabetic foot infections (DFIs) and PEDIS grade 4. Wound specimens were collected by bone biopsy and sent to San Francisco VA Medical Center Microbiology Department for aerobic and anaerobic cultures. Among the 92 cases, the study resulted in a total of 410 pathogens, which 203 pathogens were from bone cultures and 207 pathogens were from soft tissue cultures. 74% of cases were polymicrobial and 26% had growth of a single organism. Staphylococcus aureus presented in 49.35% of bone cultures and 55.38% of soft tissue cultures, Streptococcus species presented in 44.16% and 36.92% respectably and roughly 33% of both bone and soft tissue had staphylococcus coagulase negative present. Gram-negative organisms occurred in 25% of all cultures taken. Pseudomonas accounted for 15% of soft tissue infections but only 1.3% bone cultures. MRSA was found in 17.39% of cultures and VRE was seen in 4.34% of all culture results. Staphylococcus aureus was the most prevalent organisms seen. This study presents a comprehensive microbiological survey of diabetic patients with DFIs within the San Francisco VA Medical Center and this study will help guide physicians to improve clinical outcomes of DFIs by using proper antibiotics.