A 66-year-old man with type 2 diabetes of 30 years' dura-
tion and severe occlusive peripheral vascular disease had a chronic non-healing ulcer affecting his right great toe (Fig. 8.30a). The ulcer became infected and the patient developed dry gangrene of the hallux with cellulitis of the foot. The gangrenous right hallux was amputated, and 3 days later the patient underwent a right femoral to dor-salis pedis bypass graft. The amputation site remained dry and necrotic with no evidence of healthy granulation tissue. We believed that the wound would not heal, and 1 week later, the patient was brought back to the operating room for a definitive transmetatarsal amputation (Fig. 8.30b,c). The procedure was performed under spinal anaesthesia, without a tourniquet.
This was a challenging case that stretched the indications and limits for a transmetatarsal amputation. The success of a transmetatarsal amputation depends upon the presence of healthy plantar skin, for the creation of a plantar flap. In this case, gangrene and tissue loss extended on to the plantar skin, effectively narrowing the plantar flap. Preparing the flap in a normal manner would have left a large uncovered defect on the medial aspect of the amputation stump. To remedy this, we developed a long laterally based plantar flap, which was rotated medially to cover the wound. The operation was success ful and the patient has a functional, durable foot that has remained lesion free for the past 3 years (Fig. 8.30d).
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