Anatomic Limitations of the Transmetatarsal Amputation With Consideration of the Deep Plantar Perforating Branch of the Dorsalis Pedis Artery.

The transmetatarsal amputation is considered a durable procedure with respect to limb salvage when managing the consequences of diabetic foot disease. The success of the procedure is, in part, determined by the preoperative appreciation of arterial and functional status. The objectives of the present investigation were to determine the length of the remaining first metatarsal required during transmetatarsal amputation to preserve the anastomotic connection of the deep plantar perforating artery and subsequent "vascular arch" of the foot and the insertion of the tibialis anterior tendon. The primary outcome measure of our investigation was a measurement of the distance between the first metatarsal-medial cuneiform articulation and the distal extent of the deep plantar perforating artery in 85 embalmed lower limbs. As a secondary outcome measure, the insertion of the tibialis anterior tendon was evaluated relative to the deep plantar perforating artery. The most distal extent of the deep plantar perforating artery was observed at a mean ± standard deviation of 15.62 ± 3.74 (range 6.0 to 28.28) mm from the first metatarsal-medial cuneiform articulation. Most (89.41%) of the arteries were found within 20 mm of the first metatarsal-medial cuneiform articulation. The insertion of the tibialis anterior tendon was found to be proximal to the deep plantar perforating artery in all specimens (100.0%). In conclusion, 2.0 cm of remnant first metatarsal might represent an anatomic definition of how "short" a transmetatarsal amputation can safely be performed in most patients when considering the vascular and biomechanical anatomy.

Application of the five stages of grief to diabetic limb loss and amputation.

A potentially underappreciated member of the multidisciplinary approach to diabetic limb salvage is that of psychiatry. Diabetic patients are more likely to experience depression, and diabetic patients with depression are more likely to undergo an amputation. Also, both diabetes and depression independently increase the healthcare costs in the United States. The objective of the present investigation was to increase knowledge among diabetic foot practitioners with respect to psychiatric and other mental health patient-care issues, specifically the potential application of the 5 stages of grief to diabetic limb loss and amputation. We enlisted the assistance of a clinical professor from the psychiatry department at our institution to review the 5 stages of grief, provide context specific for application to diabetic limb loss, and offer clinically relevant guidelines for surgeons to better understand and communicate with their patients at each stage. The 5 stages reviewed were denial, anger, bargaining, depression, and acceptance. We hope that the present review will increase the body of knowledge with respect to relevant psychiatric issues and the diabetic foot and provide a starting point for increased awareness with respect to this important, yet underappreciated, aspect of patient care.