Transmetatarsal Foot Amputation Surgery Technique guide by Dr. Kolodenker Diabetic Foot

Source: - Dr. Gennady Kolodenker, DPM

hi this is dr. Cole Denker and now we're going to go over a distal transmitter tarsal amputation today prior to doing the surgery you want to use a marking pen and draw out your incision placement the amount of skin that you take off should be just the right amount. basically you want to go just proximal to the necrotic edges making sure that you are going into healthy skin to increase chance of healing and leaving as much skin as possible

I typically use a 10 blade and go directly down to bone with the incision this elevates a thick flap there's really minimal other dissection that is needed try to keep the blade perpendicular to the skin and ten blade seems to work best for the initial cut same thing on the planner surface keep perpendicular to the skin try to anchor your hand against something so you don't accidentally slip these are Salvage procedures that are done to minimize further progression of necrosis or infection in this case you can see that the gangrene is dry it has been here for approximately four or six weeks it starts to mummify now use a key elevator to peel back some of the periosteum off the metatarsal shafts since this is a very distal type of amputation

the osteotomies are performed at around the necks just proximal to the necks of the metatarsals typically recommended is starting with the second metatarsal this one is going to be the longest left metatarsal you want to remember to create a good parabola weight bearing surface that is even for walking and so the osteotomies are made from dorsal - planner and distal to slightly proximal as you get to the fifth metatarsal you slightly angle it a little more so that way it's distal lateral to plantar medial and the opposite is done on the first metatarsal it's going to be distal medial to plan or lateral

I would tourniquet inflated at this time minimizes the bleeding it allows this procedure to be done a little faster with less blood loss make sure that when you go to take out the first metatarsal region that you incorporate the sesamoid assess point should not be left behind here you can see the flexor tendons the sesamoid apparatus is attached to the plan of first metatarsal head

here I use a 15 blade it is more accurate and just go above the flexor tendons the entire forefoot will come out in one piece things to be careful with is when you do end up making these osteotomies more proximal you've got that dorsalis pedis artery to worry about that you got to make sure it's going to be clamped off a lot of times needs to be tight off when the osteotomy czar this distal usually just cauterizing is sufficient so the four foots come out you're gonna see the flexor tendons remain those need to be pulled and

cut they are a vascular now so there's really no reason of having them around you can use a pickup so at this point the tourniquets deflated and flaps evaluated you're going to notice some bleeding utilizing a quarter is going to be enough irrigation was done and then gloves should be changed so now you begin the clean part of the procedure or your suturing things up remember to handle the skin edges with a lot of care don't pinch them very hard and then don't tie this overly tight to create too much tenting of the skin

I usually end up using it three or two a Vicryl for the deeper aspect any suturing bring the flap together and then I bury my knots after that we're gonna use a prolene suture mix between 200 and 300 prolene with simple sutures and sometimes horizontal mattress when needed sometimes you're left with a dog ear so probably take care of the dog ear and remember that best option is to remain non-weight-bearing during the healing process which can take two or three weeks the less walking that is occurring here the less the more likely the skin edges will come together and then it will make very much faster recovery for the patient early weight-bearing can create a lot of dehiscence and the flap and

then you're dealing with wound care issues for final pictures and find results you can visit the link on the bottom of this video you'll see I'll take periodic pictures and you'll end up seeing the final product on the website if you have any questions about transmitted or some mutation feel free to post have a great day