Point-Counterpoint: Is An Initial TMA Better Than A Partial Ray Amputation in Patients With Diabetic Neuropathy?

Valerie L. Schade, DPM, AACFAS, and Suhad Hadi, DPM, FACFAS

Comparing The Success Rates Of Various Levels Of Amputation

Cohen and colleagues performed a retrospective review of 53 male patients with peripheral neuropathy who had a partial ray resection, panmetatarsal head resection or TMA.3 Thirty-three patients (35 feet) had an isolated ray resection. The average follow-up time was 28 months. The overall success rate was 37 percent. Individual success rates for isolated ray resections were 36 percent for the first ray, 14 percent for the second ray, 17 percent for the third ray, 0 percent for the fourth ray and 78 percent for the fifth ray. The most common complication was transfer ulceration resulting in infection and the need for further amputation. Six patients (a total of seven feet) had panmetatarsal head resection.3 The average follow-up time was 17 months with a success rate of 86 percent.

   Fourteen patients (15 feet) had a transmetatarsal amputation. The average follow-up time was 17 months. There were adjunctive procedures in six feet.3 These procedures included Achilles tendon lengthening, anterior tibial tendon transfer to the peroneus tertius tendon, transfer of the extensor hallucis longus tendon to the anterior tibial tendon insertion, transfer of the anterior tibial tendon to the peroneus tertius tendon, and transfer of the extensor hallucis longus to the posterior tibial tendon. Complications occurred in three patients. One patient developed a new ulceration at the distal aspect of the residual foot that required a full thickness advancement flap and Achilles tendon lengthening to heal. One patient had delayed healing and required revision of the residual second metatarsal. Finally, one patient who was discharged with an open plantar flap and lost to follow-up for 14 months ended up with an above-knee amputation. None of these patients had any tendon balancing procedures at the time of their index TMA. Their reported success rate following a TMA was 93 percent.

   In the study, more than 60 percent of patients who had an isolated ray resection developed a new or recurrent ulceration more than 24 months following their index procedure.3 Given that, the authors concluded that one should relay these risks to the patient at the initial presentation and stressed the importance of close postoperative monitoring. They felt that a TMA was a more stable and reliable procedure. The authors also stressed the importance of considering adjunctive tendon and osseous balancing procedures to combat the remaining flexible or rigid equinovarus deformity in order to minimize the risk of ulceration, infection and further amputation.

   Brown and coworkers compared the morbidity, mortality, requirement of more proximal ipsilateral amputation and functional outcomes among patients who had a BKA, TMA, Chopart amputation, partial calcanectomy and total calcanectomy.4 Patients who had a TMA had a lower rate of mortality in comparison to those who underwent a BKA at one, three and five years postoperative with statistical significance at one and three years. The rate of reamputation following a TMA was 0.09. Of the 21 patients who had a TMA, only two patients (10 percent) required more proximal ipsilateral amputation. One patient had the second amputation at 0.3 years and another patient had it at 4.2 years following the index procedure. The study did not state the reason for re-amputation.

   Assessing postoperative ambulatory status with the validated Volpicelli scale, Brown and colleagues found that patients who underwent a TMA remained as unlimited household ambulators.4 The study authors determined that a TMA provided a predictable, durable and functional residual limb.

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