Baseball flap closure for transmetatarsal amputation with complex soft tissue deficits

Abstract

This case study aims to demonstrate a one stage baseball flap transmetatarsal amputation (TMA) technique consisting of combined lateral plantar artery angiosome rotational flap (LPAA) and both dorsal and plantar hallux digital fillet flaps for coverage of a complex central and lateral wound with chronic osteomyelitis. A 67 y/o male with type 2 diabetes mellitus and alcoholic cirrhosis, who previously underwent partial 2nd ray amputation at an outside hospital, presented with osteomyelitis in multiple metatarsals and large plantar and lateral soft tissue defects. After initially refusing surgical treatment due to complex social issues, the patient underwent a single stage TMA with wide excision of the wounds and fibrotic surgical site, complete 5th ray amputation, partial resection of the cuboid, peroneus brevis tendon transfer, bone biopsy of multiple metatarsals, and multiple flap closure. A LPAA flap was combined with split hallux dorsal and plantar digital fillet flaps to accomplish a single stage “baseball” flap TMA. The plantar hallux digital fillet flap was used to cover a large central plantar soft tissue deficit, which left a dorsal distal defect that was covered with the dorsal hallux flap. The patient was non-weight bearing for 6 weeks and then progressed to walking over then following 4 weeks. The patient was fully healed by 10 weeks post-operatively without subsequent revision surgeries or other complications with intermediate term follow up. This case details patient selection criteria, flap design principles, and surgical technique pearls.

Keywords

• Transmetatarsal amputation
• Hallux digital fillet flap
• Osteomyelitis
• Infection
• Soft tissue coverage
• Angiosomes