A Guide To Digital Amputations In Patients With Diabetes

Alexander Reyzelman, DPM, and Jamie Kim, DPM

Digital amputation has the potential to allow patients with diabetes to resume daily activities with few alterations in gait. Accordingly, these authors discuss proper procedure planning, how to ensure appropriate vascular supply and key surgical pearls.

Most podiatrists who treat patients with diabetes at some point will encounter a patient in need of a partial or complete digital amputation. These patients typically have had exhaustive treatments including various wound therapies, surgical debridements, antibiotics as well as incision and drainage. The indications for digital amputation include osteomyelitis, septic arthritis, gas gangrene, ischemia/gangrene and an advancing soft tissue infection.

   In certain patients, an elective partial toe amputation may be advisable. These patients who do not have an active infection may suffer from a rigid hammertoe deformity with a non-healing ulcer on the tip of their toe. In these situations, partial digital amputation would address the hammertoe deformity and the non-healing ulcer at the same time. A candidate for this type of a procedure would be a patient who is elderly, someone who has multiple comorbidities or an individual with minimal mobility who would benefit from a quick and easy procedure with minimal postoperative healing time.

   Typically, one can avoid higher level amputations with early digital amputations that allow patients to return to normal activities with minimal disability.

   Accordingly, let us take a closer look at the senior author’s approach to digital amputations including appropriate preoperative evaluation, incision planning and pearls in performing various digital procedures.

   There are many benefits of more distal amputations in comparison with amputations at a higher level. Distal amputations are more functional and have many physiological benefits such as energy preservation during ambulation.1,2

   In a study of eight patients who had undergone partial foot amputations and a cohort of matched non-amputee control patients, Dillon and Barker report that amputations distal to the metatarsophalangeal joint (MPJ) had little impact on the normal pattern of ankle power generation.3 Distal amputations are preferred to proximal amputations as they preserve length and therefore normal biomechanics of the foot. The simple rule of thumb is to save as much length as possible when performing partial foot amputations.

What You Should Know About Lesser Toe Procedures

When performing central toe amputations, it is important to make an effort to leave a segment of the proximal phalanx intact. Leaving a stump of the second, third or fourth toe intact allows the stump to function as a buttress, preventing the adjacent toes from developing a shift in the transverse plane. Amputations of lesser digits generally result in a gait with minimal to no disturbance.

   Questions frequently come up as to whether a guillotine amputation of the toe is appropriate. In our facility, we prefer to avoid guillotine amputations and make an effort to plan the incision in order to close the wound primarily or in a delayed primary fashion. In order to perform closure of the amputation site, we often carry out more proximal bone resection to allow tension free closure. Although guillotine amputation of the toe can preserve length, the risk of leaving an open wound to heal via secondary intention does not outweigh the benefit of primary closure when possible.

   The preferred incision for a partial toe amputation is a transverse fish-mouth incision, which tends to give the best outcome both cosmetically and functionally.

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