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Introduction
Diabetic foot is a complicated syndrome that is comorbid with several diabetic complications, such as peripheral arterial disease (PAD) and peripheral neuropathy. It was reported that 10% of diabetic patients will develop this syndrome at least once during their lifetime [1]. Patients with diabetic foot ulcers (DFUs) may undergo minor or major amputation, which will have a considerable impact on patients’ life expectation, quality of life and economic burden. Among minor amputations, transmetatarsal amputation (TMA) appears to be the most convincing in terms of limb salvage rates and in maintaining foot and ankle biomechanics for DFU patients with forefoot necrosis and infection. Under current clinical practice, vascular intervention, anti-infection treatment, surgical operation and postoperative wound care have been performed. However, the reported TMA wound healing rates from multiple series were not good (range, approximately 40–70%) [2, 3, 4, 5, 6, 7–8].
Around half of patients with DFU have co-existing PAD [9, 10], which is considered the most significant limiting factor for healing of ischemic DFU [11]. Therefore, many researchers had implemented revascularization before the definitive surgical procedure or before final wound closure in DFU patients who needed partial foot amputation to improve ischemia. However, the postoperative limb salvage rates or healing rates in DFU subjects receiving revascularization were still low [3, 4, 6, 12]. DFU patients who have indications for TMA always have forefoot gangrene resulting from severe atherosclerotic lesions below the tibial arteries, microangiopathy, infection and severe comorbid conditions. Revascularization for these patients is, therefore, considered inappropriate or has limited effects after operation [13, 14–15].
Up to now, few published outcomes of DFU patients without revascularization existed. Therefore, we recruited DFU patients who were not candidates for revascularization who had undergone TMA to observe the outcomes.
Methods
Patient Selection
From July 2012 to December 2016, 148 type 2 diabetic patients underwent TMA in our diabetic foot unit. All the patients had forefoot gangrene with more than one toe involved and 30 of them had undergone toectomy but failed to heal. One hundred two patients who were not candidates for revascularization because of severe comorbidity, nonambulatory status, inadequate outflow vessels, patients’ refusal or other conditions not accepted by vascular surgeons were selected.
As this was a follow-up observational study, and there was no intervention...