Use of the Allgöwer-Donati Suture Technique for Wound Closure Following Transmetatarsal Amputation

Partial foot amputations carry higher inherent risks for complications compared with other procedures because they are often necessary in cases of infection, gangrene, and/or vascular disease. In a study of early failure after forefoot amputation, Zambetti et al¹ reported that 28.6% of patients had complications (wound and non–wound-related) within 30 days. Those authors also reported a 15.8% readmission rate. 

Successful TMA has been shown to be a durable procedure for diabetic limb salvage, however.² Surgeons can take steps preoperatively, perioperatively, and postoperatively to reduce the risk of complications. Selection of wound closure technique to prevent skin ischemia is one such step. 

Studies of trauma incisions and an animal study found the Allgöwer-Donati suture technique to be the suture technique least detrimental to skin perfusion at the incision site.^3-5 This suture has historically been recommended and studied in trauma scenarios such as fibula incisions in the management of pilon and ankle fractures as well as calcaneal fractures. To the knowledge of the authors of the present study, use of the Allgöwer-Donati suture technique for foot amputation in the setting of infection or gangrene has not been studied. Foot amputations are often in the face of decreased perfusion through peripheral arterial disease and microvascular disease in persons with diabetes. Facilitating increased skin perfusion without compromising closure integrity would be beneficial and may decrease wound complications and dehiscence at amputation sites. 

A multitude of approaches are available to foot and ankle surgeons to promote skin healing after partial foot amputation, and these approaches have been well studied. Graft application, collagen and/or antibiotic powders, negative pressure wound therapy, flap handling, delayed closure, revascularization, nutrition supplementation, and weightbearing status are among the factors that affect healing after amputation. Historically, selection of suture technique to achieve skin closure has mostly been left to physician preference. TMA has a major potential risk of skin dehiscence and wound complications that may lead to morbidity and more proximal amputation.^6,7 

In the present case series, TMA incisions were closed with multilayer absorbable sutures for deep coverage and nylon sutures for skin closure using the Allgöwer-Donati technique. This closure technique was used because of the increased skin perfusion levels with it compared with other common skin suture methods and the resulting potential for decreased incisional ischemia and fewer skin healing complications. A case series of 7 patients (8 limbs) who underwent TMA using the Allgöwer-Donati closure technique is presented.

The records of patients who underwent TMA between March 2021 and March 2022, all of whom were treated by a single surgeon (JT), were retrospectively identified and reviewed according to the ethical guidelines at the senior author’s institution (JT). Only patients with a diagnosis of gangrene were included in the study; disease processes that resulted in gangrene varied. Neither Achilles lengthening adjunct procedures nor bilateral procedures were excluded. Patients with plantar forefoot ulcerations or who required staged closure were excluded. Seven patients were identified, with 1 patient requiring simultaneous bilateral TMA. 

Patient demographics and wound characteristics are detailed in the Table. Five of the 8 limbs managed with TMA and the Allgöwer-Donati suture technique healed uneventfully (62.5%), with an average time to healing of 3.3 weeks. One limb (12.5%) required local wound care after dehiscence but went on to heal at 4 weeks. One limb (12.5%) did not heal and required revision proximal amputation. One limb (12.5%) required local wound care and was lost to follow-up. 

Case 1

A 41-year-old male with end-stage renal disease, hepatitis C, and endocarditis sustained a right forefoot ischemic injury secondary to use of vasopressors and underwent TMA. The incision was closed using the Allgöwer-Donati suture technique and healed without complications at 3 weeks; Figure 1 shows healing progression at 2 weeks. Heel weightbearing as tolerated in a surgical shoe was allowed immediately after surgery. 

Case 2

A 29-year-old female with endocarditis and a history of intravenous drug use sustained a right forefoot ischemic injury secondary to use of vasopressors and underwent TMA. Figure 2 shows the sutures intact at day 2. The incision was closed using the Allgöwer-Donati suture technique, and healing occurred without complications at 2 weeks. Heel weightbearing as tolerated in a surgical shoe was allowed immediately after surgery.

Case 3

A 60-year-old male with a history of tobacco use and severe peripheral vascular disease with right forefoot gangrene had a right ankle-brachial index of 0.24 at presentation and underwent femoral popliteal bypass to the right lower extremity. Two days later, right TMA was performed by a podiatrist; Figure 3 shows healing 2 days postoperative. The incision was closed using the Allgöwer-Donati suture technique, and healing without complications was achieved at 3 weeks. Weightbearing as tolerated in a surgical shoe was allowed immediately after surgery.

Case 4

A 58-year-old male with chronic kidney disease, atrial fibrillation, and coronary artery disease required extracorporeal membrane oxygenation after a diagnosis of COVID-19 and respiratory failure. Ischemic injury and right forefoot gangrene were noted as well as a severe equinus contracture for which a podiatrist was consulted. Right TMA and open Achilles tendon lengthening were performed. The right TMA site was closed using the Allgöwer-Donati suture technique. Postoperatively, the patient was kept nonweight-bearing for 6 weeks in a controlled ankle motion boot with the ankle in neutral position. Minor wound dehiscence at the amputation site was treated with local wound care. Sutures were removed, and complete healing at the amputation site was observed at 4 weeks. 

Case 5

A 56-year-old female with type 2 diabetes mellitus and peripheral vascular disease underwent left TMA owing to gangrene of the left forefoot. The patient had a left ankle-brachial index of 0.63. The incision was closed using the Allgöwer-Donati suture technique. Wound dehiscence at the incision site was managed with local wound care. Heel weightbearing as tolerated in a surgical shoe was allowed immediately after surgery. The patient was lost to follow-up, and time to healing is unknown.

Case 6

A 53-year-old male with type 2 diabetes complicated by severe peripheral neuropathy and peripheral vascular disease required right TMA secondary to a diabetic foot infection. The incision was closed using Allgöwer-Donati suture technique, and wound healing was as expected 10 days postoperatively. However, soon after the patient progressed to dehiscence and a nonhealing incision. The patient underwent revision Chopart amputation with gastrocnemius recession. Weightbearing as tolerated in a surgical shoe was allowed immediately after TMA surgery.

Case 7

A 44-year-old male with a history of methamphetamine use, neuropathy, and homelessness required bilateral TMA owing to frostbite. The ankle-brachial index was 1.22 in the right lower extremity and 1.13 in the left lower extremity. In both lower extremities the incisions were closed using the Allgöwer-Donati suture technique, and the surgical sites were healed at 4 weeks. Weightbearing as tolerated in surgical shoes was allowed immediately after surgery.

TMAs may be the final option for limb salvage in patients with infection, gangrene, osteomyelitis, or nonhealing wounds of the forefoot. Such amputation can allow for the functional preservation of the foot in order to maintain ambulatory function and decrease morbidity; however, wound healing problems are often a major complication in these patients.6 Wound healing rates reportedly range from approximately 40% to 70%, which puts patients at considerable risk of more proximal amputation.⁸ Patients may be resistant to proximal amputation, and ambulation with a proximal amputation and prosthesis may be more difficult than ambulation with a partial foot amputation. Poor ambulatory performance in patients with atherosclerosis who have undergone transtibial amputation is well documented.⁶ Thus, despite the reported lower healing rates with TMA, it is recommended that the procedure be performed when indicated.

In a prospective, randomized study of lateral incisions in the management of ankle fractures, Shannon et al³ reported improved perfusion with the Allgöwer-Donati suture versus the vertical mattress suture. The 2 groups were compared by measuring incision perfusion in fluorescence units with laser-assisted indocyanine green angiography. There was no difference between the groups in wound complications despite increased perfusion in the Allgöwer-Donati group. Sagi et al⁵ found the Allgöwer-Donati suture to be superior to simple, vertical mattress, and horizontal mattress sutures as measured using LDF in a porcine model. LDF was used to measure cutaneous blood flow, and increased perfusion was noted with the Allgöwer-Donati suture. 

Shorten et al⁹ conducted a prospective, randomized study to measure incision perfusion in fluorescence units with laser-assisted indocyanine green angiography in patients undergoing ankle fracture surgery. A total of 75 patients were randomized to groups of 15 treated with 1 of 5 suture patterns: simple, vertical mattress, horizontal mattress, Allgöwer-Donati, or running subcuticular. Of these 5 suture types, subcuticular sutures had significantly higher mean incision perfusion rates and significantly lower mean perfusion impairment. Interestingly, no difference was found in mean incision perfusion between Allgöwer-Donati and vertical mattress sutures; however, a lower mean incision perfusion impairment was noted with the Allgöwer-Donati suture. Those authors concluded that the mean incision perfusion and incision perfusion impairment values of the subcuticular and Allgöwer-Donati suture patterns support the use of these sutures over the others.⁹ Subcuticular sutures typically are not recommended in patients who require partial foot amputations as the result of vascular impairment, neuropathy, or infection.

This case series has several limitations. It is retrospective and includes a limited number of patients and TMAs. Multiple causes of necrosis leading to TMA were presented, with differing healing potential and perfusion. Weightbearing protocol also varied by individual patient and based on the need for adjunct procedures.

The Allgöwer-Donati suture has been shown to have increased skin perfusion at the incision site compared with other sutures. The authors of the present study note that this suture may be useful after partial foot amputation in patients with compromised blood supply. In the present case series, the suture withstood weightbearing in ambulatory individuals and demonstrated promising outcomes. The Allgöwer-Donati suture technique has historically been recommended for and studied in trauma scenarios; however, the present study demonstrates its application to limb salvage. Further research is needed to support this hypothesis as this study did not prove the reported technique equivalent, let alone superior. A suture technique that decreases incision perfusion impairment may result in improved healing rates for TMAs and partial foot amputations with a tenuous blood supply. Despite the Allgöwer-Donati suture technique being associated with higher skin perfusion, while this technique withstood weightbearing, in this small case series it did not show superiority to other reported methods of TMA closure based on this case series.