Point-Counterpoint: Is An Initial TMA Better Than A Partial Ray Amputation in Patients With Diabetic Neuropathy?
A Closer Look At The Author’s Experience
My colleague and I performed a retrospective review of patients with peripheral neuropathy who underwent a TMA at our facility over a six-year period.5 The review excluded patients if they required a higher level of amputation secondary to progressive necrosis or infection. A total of 17 patients (17 feet) met all of the inclusion criteria. The mean age was 69 years. The mean follow-up time was four years. All patients had adjunctive tendon balancing procedures consisting of an Achilles tendon lengthening to combat equinus. Each patient also had either a peroneus brevis to peroneus longus tendon transfer, a split tibialis anterior tendon transfer, a flexor hallucis longus transfer, an extensor digitorum longus transfer, a posterior tibial recession or internal hardware to combat varus deformity of the foot.
More than 50 percent of patients admitted to not using a custom insert and/or ambulating barefoot.5 Despite this, only three patients (18 percent) developed an ulceration. One was due to a flexible equinovarus deformity that healed with use of an AFO, one was due to a limb length discrepancy secondary to a chronically infected total hip arthroplasty on the contralateral limb that also healed with the use of an AFO and one was continuing care with another provider and was lost to follow-up. This put our overall success rate at 94 percent, similar to the finding by Cohen and colleagues.3,5
Any loss of the foot puts an emotional toll on the patient. The need for perpetual follow-up for prolonged antibiotic therapy, delayed healing, wound recurrence or occurrence, and further amputation can further exacerbate this emotional toll as well as place physical and financial burdens on the patient. Existing evidence demonstrates that an isolated ray resection does not result in a durable and functional foot, and has a poor prognosis for longevity. The future focus needs to be on form and function in the form of a well-balanced TMA to combat residual equinovarus deformity of the foot and away from the minimalist efforts of the past to eradicate infection.
Dr. Schade is the Chief of the Limb Preservation Service at Madigan Army Medical Center in Tacoma, Wash. She is an Associate of the American College of Foot and Ankle Surgeons.
1. Borkosky SL, Roukis TS. Incidence of re-amputation following partial first ray amputation associated with diabetes mellitus and peripheral sensory neuropathy: a systematic review. Diabet Foot Ankle. 2012;3. doi: 10.3402/dfa.v3i0.12169. Epub 2012 Jan 20.
2. Borkosky SL, Roukis TS. Incidence of repeat amputation after partial first ray amputation associated with diabetes mellitus and peripheral neuropathy: an 11-year review. J Foot Ankle Surg. 2013;52(3):335-8.
3. Cohen M, Roman A, Malcolm WG. Panmetatarsal head resection and transmetatarsal amputation versus solitary partial ray resection in the neuropathic foot. J Foot Surg. 1991;30(1):29-33.
4. Brown ML, Tang W, Patel A, Baumhauer JF. Partial foot amputation in patients with diabetic foot ulcers. Foot Ankle Int. 2012;33(9):707-16.
5. Omana-Daniels R, Schade VL. Is an Achilles tendon lengthening with a TMA enough? Poster presentation, The Desert Foot Conference, Phoenix, AZ, November 2013. Available at http://www.podiatry.com/images/desertfootsite/abstract/13/Schade_Achille... . Accessed April 13, 2014.
This author says with the proper protocol in place, first ray amputations can provide good long-term healing and functional outcomes.
By Suhad Hadi, DPM, FACFAS
The growing emphasis on limb salvage and multidisciplinary approaches to care has brought on an apparent decline in the number of major lower extremity amputations with a noted increase in the number of foot level amputations.1-4 With the change in prevalence, there is much controversy surrounding decision making in regard to “definitive” foot level amputations.