The authors performed a retrospective review of prospectively collected data of all diabetic patients who underwent transmetatarsal amputation (TMA) for toe gangrene or neuropathic ulceration from May 2006 to June 2009. Twenty-nine TMAs were performed in diabetic patients during the study period, including 24 men and 5 women with a mean +/- SD age of 66.3 +/- 7.5 years. The indications for TMA were gangrene of > or = 2 digits in 12 patients (41%) and neuropathic ulceration with underlying osteomyelitis or abscess and a concomitant dysfunctional forefoot in 17 patients (59%). Of the 12 patients who presented with toe gangrene, 7 (58%) underwent endovascular intervention and 5 (42%) underwent open vascular bypass. Equinus contracture was present in 27 patients (93%), and 26 (96%) of these patients underwent tendo-Achilles lengthening or gastrocnemius recession. Correction of equinus contracture was not performed in 1 patient as it was deemed not feasible. Forefoot varus deformity was present in 22 (76%) patients, and balancing was performed in 17 of these patients (77%) with skeletal stabilization or tendon transfer. Balancing was not performed in the remaining patients as it was not necessary or not feasible. Sixteen patients (55%) healed primarily and 5 patients (17%) developed minor wound separation that healed via secondary intention. An additional 4 patients were able to maintain functional revision procedures confined to the foot (1 TMA revision, 3 Chopart amputations). Three patients (10%) required below-knee amputation, and there were 2 deaths (7%) during the time period. Functional amputation confined to the foot was achieved in 86% of ambulatory diabetic patients. These results support a more aggressive initial approach in ambulatory diabetic patients with multiple digital ulcerations, allowing this patient population to remain functional and avoid multiple reoperations and ultimately major amputation.