Transmetatarsal or Below-Knee Amputation? Why Saving Part of the Foot Matters

Hearing that part of your foot can’t be saved is hard news. Often the choice is between two operations: a transmetatarsal amputation (TMA), which removes the front of the foot, and a below-knee amputation, which removes the foot and the lower leg. Here is how they compare, and what tips the choice. For every foot-level operation, see toe and partial foot amputation; if you’ve been told you need a leg amputation, read about a limb salvage second opinion.

What each operation removes and keeps

Transmetatarsal amputation. A TMA removes the toes and the front part of the five long bones behind them (the metatarsals), keeping the heel, the arch and the ankle joint. Keeping the ankle and as much of the foot’s length as possible is meant to give a more natural walk, less effort with each step and a better quality of life.⁠^[1] You then walk in a shoe with a custom insert and toe filler rather than on an artificial leg; in a review of 59 studies, devices like these improved walking speed and spread pressure more evenly across the sole.⁠^[4]

Below-knee amputation. The foot, the ankle and the lower part of the shin are removed, and walking afterward depends on an artificial leg (a prosthesis) and rehabilitation. In a review of 57 studies, people with a lower amputation, younger people and those who were more mobile before surgery generally walked better with a prosthesis.⁠^[5]

Dr. Efe Ozturk, a Foot and Ankle Surgeon board certified in wound care (FAPWH), performs toe, ray, transmetatarsal and midfoot amputations when a foot needs one, though most people we see for foot wounds won’t. Below-knee amputation is outside a foot and ankle practice; if it is ever the right choice, a vascular or orthopedic surgeon performs it.

Why keeping the heel and ankle matters

The case for a TMA rests on walking. In a classic study of 70 people walking with a prosthesis after amputation above the knee, below the knee or at the ankle, walking was better the lower the level, and the authors advised the lowest possible level when function matters most.⁠^[6] In a smaller study of 25 people with amputations for poor circulation, from the midfoot to above the knee, walking was slower and used more oxygen per meter the higher the level; the authors noted that such patients already walk near their maximum capacity.⁠^[7]

Direct comparisons are few. One university hospital reviewed eight years of records for 367 people: 74 had a TMA and 293 a below-knee amputation. At the last follow-up visit, 56.8% of the TMA group were walking, compared with 30.9% of the below-knee group, though more of the TMA group needed another operation.⁠^[2] At a limb salvage center that followed 146 high-risk people for about two years after a TMA, 88% still had their leg and 83% were walking.⁠^[8]

The table draws on one hospital’s records,⁠^[2] a small energy study that also included people without an amputation,⁠^[9] and a review that found too little quality-of-life research to settle the question.⁠^[10]

The catch: a TMA has to heal

A TMA doesn’t always heal the first time. When researchers pooled 22 studies covering 1,569 closed TMAs, 67% healed; along the way, 17% developed an infection after surgery and 29% had the wound edges come apart.⁠^[3] An earlier review of 24 reports estimated that about 1 in 4 people needed another operation and about 3 in 10 eventually had a major amputation.⁠^[11]

In a series of 265 people who had a TMA, 27% later needed an amputation above the ankle. The surgeons advised realistic expectations and team care: careful technique, correcting poor blood flow or a tight tendon when present, and getting general health ready beforehand.⁠^[12]

What helps a TMA heal and last

• Blood flow. In a study of 346 TMAs, feet with artery disease healed less often than feet without it (64% vs 77%).⁠^[13] International guidelines suggest measuring toe pressure in a foot with an ulcer or gangrene: a toe pressure of 30 mmHg or more raises the likelihood of healing by up to 30%. When tests show poor circulation, they advise considering a procedure to restore flow and consulting a vascular specialist, unless a major amputation is medically urgent.⁠^[14] We start with noninvasive circulation testing at our practice (see circulation tests for foot wounds and why toe pressures can tell more than ankle pressures) and coordinate revascularization with vascular specialists.
• Infection under control. At the limb salvage center above, infection after surgery was far more common in people whose TMA later failed (39% vs 9.5%).⁠^[8] When a foot is infected, Dr. Ozturk drains the infection and removes dead tissue first, aiming to close the amputation in a clean wound. See diabetic foot infections and does osteomyelitis mean amputation?
• Blood sugar. In one surgeon’s series of 230 TMAs, each 1% rise in hemoglobin A1c raised the odds of a later major amputation by 24%.⁠^[15] We work with your diabetes doctor before surgery; see preparing for limb salvage surgery.
• Tendon balance. New sores on the end of the foot are a common late problem; one explanation is that losing the tendons that lift the toes lets the Achilles tendon slowly tighten. In one study, these sores developed in 35% of feet after a TMA alone, compared with 3% when the Achilles tendon was lengthened at the same operation; lengthening has small risks of its own, and 2 of 35 lengthened tendons ruptured.⁠^[16] Dr. Ozturk can add it when the foot needs it; see Achilles lengthening for forefoot ulcers.

When a below-knee amputation is the wiser choice

A TMA isn’t right for everyone, and choosing a below-knee amputation can be a sound decision, not a defeat.

• When healing is out of reach. International guidelines advise against a procedure to restore blood flow when its chance of success is clearly poor, and their reasoning includes cases with no realistic chance of the wound healing or where a working foot is unlikely.⁠^[14]
• When several risks stack up. In a Swedish series of 560 TMAs, people with artery disease but no diabetes more often needed an amputation above the ankle; they were older, had more medical problems and more advanced ulcers, and the authors cautioned that a TMA may be futile when several such risks combine.⁠^[17]
• When healing is the priority. Some rehabilitation researchers argue for choosing the level mainly on the chance of healing, which may favor a below-knee amputation in many cases: fewer complications and repeat amputations, with walking and energy use that look similar in their reading of the evidence.⁠^[1]

What the research can’t tell you yet

Most of this evidence comes from hospital records rather than randomized trials. People who have a below-knee amputation are often sicker to begin with: a systematic review found a higher risk of death after below-knee than after partial foot amputation, which the authors thought may reflect more advanced disease rather than the level itself. It called the overall evidence limited and suggested that mobility and quality of life may be similar after either level.⁠^[18] The energy argument isn’t settled either: the small 2025 study found no significant difference between the TMA and below-knee groups, and its authors called for larger studies.⁠^[9] No one can promise that a TMA will heal or make walking easier; the level is chosen with you, based on your circulation, infection, health and goals.

Life after a transmetatarsal amputation

After healing, the work shifts to protecting what you kept. With numb feet or artery disease, a past amputation puts you in the highest-risk group, and guidelines advise a foot check every 1–3 months.⁠^[19] We fit therapeutic shoes and custom inserts shaped to your new foot (see offloading boots and footwear and Ozturk Foot & Ankle’s diabetic foot care (external site)). New sores are covered in problems after a partial foot amputation, and the first weeks in recovery after limb salvage surgery. For nerve pain after any amputation, our sister practice, the Lower Extremity Nerve Institute, evaluates pain after a leg amputation (external site).

Common questions

Will I need an artificial leg after a transmetatarsal amputation?

Usually not in the way a below-knee amputation requires. Instead, you walk in a shoe with a custom insert and toe filler; such devices improved walking speed and pressure under the foot, though about a quarter of the studies were single-patient case reports.⁠^[4]

If a transmetatarsal amputation doesn’t heal, will I lose my leg?

Not necessarily. At one limb salvage center, 41 of 146 people needed a higher amputation, and more than half of those stayed within the foot, at the midfoot (Lisfranc or Chopart) level.⁠^[8]

Is a below-knee amputation the safer choice?

Not clearly. It led to fewer repeat operations in one comparison,⁠^[2] but studies of survival are skewed because the people chosen for a below-knee amputation tend to be sicker.⁠^[18]

Can I get a second opinion before deciding?

Yes. When circulation is poor, guidelines advise consulting a vascular specialist about restoring blood flow, unless a major amputation is medically urgent.⁠^[14] Bring your imaging and test results; see a limb salvage second opinion.

The bottom line

Keeping the heel and ankle gives many people a better chance of walking, and a transmetatarsal amputation that heals is a real limb salvage success. It is not the easier road: it heals less predictably than a below-knee amputation and often needs more than one operation. The odds improve when blood flow is restored, infection is cleared, blood sugar is controlled and the tendons are balanced. When those goals can’t be reached, a planned below-knee amputation by a vascular or orthopedic surgeon can be the more reliable route to a healed limb.