From the Departments of Plastic and Reconstructive Surgery, Orthopedic Surgery, Endocrinology, and Cardiology, Asan Medical Center, University of Ulsan, College of Medicine.
Plast Reconstr Surg. 2019 Jan;143(1):294-305. doi: 10.1097/PRS.0000000000005122.
The benefits of total transmetatarsal amputation over higher level amputation are well known. However, there are no studies evaluating the effects of first ray- or first two ray-sparing transmetatarsal amputation with flap coverage. The authors evaluated this approach with regard to functional outcome and to identify long-term complications.
Retrospective data of 59 patients were evaluated according to their surgical method. Complete transmetatarsal amputation with free flap reconstruction was designated as the transmetatarsal amputation group with 27 patients and first ray- or first two ray-preserving transmetatarsal amputation with free flap reconstruction was designated as the ray group, with 32 patients. Demographics, flap outcomes, additional procedures after initial healing, and functional outcomes were measured and evaluated.
There was no statistically significant difference in demographic distribution and flap outcomes in either group, except for poor blood glucose control in the ray group. Additional procedures after initial healing showed no statistical difference, but the tendency of minor procedures was higher in the ray group. The maximum achieved ambulatory function was significantly better in the ray group, with an ambulatory function score of 4.4 compared with 3.7 in the transmetatarsal amputation group (p = 0.012).
The preservation of the first ray or first two rays with free flap reconstruction may functionally benefit the patients despite the higher tendency toward minor procedures after initial healing. Furthermore, the progressive deformity of the preserved first and second toes will inevitably occur, requiring patients to undergo further surgery. Further studies are warranted to evaluate this approach.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
全跖骨截肢术优于更高水平的截肢术，这已得到广泛认可。然而，目前尚无研究评估保留第一跖骨或前两跖骨的跖骨截断术加皮瓣覆盖的效果。作者评估了这种方法在功能结果方面的效果，并确定了长期并发症。
根据手术方法回顾性评估了 59 例患者的数据。完全跖骨截肢加游离皮瓣重建被指定为跖骨截肢组，共 27 例，第一跖骨或前两跖骨保留的跖骨截断术加游离皮瓣重建被指定为前跖骨组，共 32 例。测量和评估了患者的人口统计学资料、皮瓣结果、初始愈合后进行的其他手术以及功能结果。
两组患者的人口统计学分布和皮瓣结果除前跖骨组患者血糖控制较差外，无统计学差异。初始愈合后的其他手术无统计学差异，但前跖骨组进行小手术的倾向较高。前跖骨组患者的最大可实现步行功能明显更好，步行功能评分为 4.4，而跖骨截肢组为 3.7（p = 0.012）。
尽管初始愈合后小手术的倾向较高，但用游离皮瓣重建保留第一跖骨或前两跖骨可能在功能上使患者受益。此外，保留的第一和第二趾的进行性畸形将不可避免地发生，需要患者接受进一步的手术。需要进一步的研究来评估这种方法。
临床问题/证据水平：治疗性，III 级。
