Point-Counterpoint: Is An Initial TMA Better Than A Partial Ray Amputation in Patients With Diabetic Neuropathy?
Patients often fear the “whittling away” effect while at the same time desiring the most minimal amputation level in effort to preserve as much of the structural integrity of the foot. This is at times a mechanism to attempt to better cope psychologically with having the amputation. At times, a partial first ray amputation can fulfill the expectation in the patient to maintain the majority of the foot. If healing parameters are optimal for this level of amputation and one implements appropriate post-amputation prosthetic and activity modifications, a partial first ray amputation can provide an acceptable level of healing and function in the long term.
The importance of function and prevention of progressive deformity are key components to selecting the appropriate amputation level. However, one cannot exclude the role of psychosocial parameters surrounding amputation. One must take into account the toll on both the patient and his or her social network. From the initial onset of ulceration, the compromise in quality of life can impact the successful outcomes in regard to ulcer healing or amputation healing should one become necessary.
The Eurodiale study found that health related quality-of-life factors measured via five domains (mobility, self-care, usual activities, pain/discomfort and anxiety/depression) influenced amputation risk and outcomes.8 Therefore, as noted in the study, we can further speculate that psychosocial and health factors may be necessary additions to the overall limb salvage efforts of the multidisciplinary team.
It is important to realize that no amputation is without its own inherent risks and appropriately weighing these risks and benefits leads to appropriate amputation level selection. One must tailor procedures accordingly in order to ensure the best outcome for the patient in regard to healing, function and quality of life issues. Appropriate perioperative planning will minimize healing complications and the risk of further amputation.1 The most success with first ray amputation occurs in patients with appropriate control of infection, optimal perioperative parameters in regard to nutrition and total lymphocyte count, optimal vascular status, appropriate implementation of adjunctive surgical management, adherence to postoperative restrictions, and long-term prosthetic fitting.1 Further experience has shown that access to a well-constructed multidisciplinary care team further encourages successful outcomes and patient adherence.
Therefore, there are several key factors that can support successful outcomes of partial first ray amputations. These factors include identifying the structural makeup of the surgical foot; access to comprehensive care; appropriate prosthetic prescriptions; identifying the need for adjunctive surgical interventions; and optimizing nutritional status and infection defenses.
Ultimately, it is important to optimize all factors for healing and recognize the equivocal findings in regard to energy expenditure, biomechanical stresses, progressive deformity and re-amputation risks associated with all foot level amputations. While we have considered transmetatarsal amputations a “more definitive” foot level amputation, they require re-amputation or major amputation in 25 to 30 percent of cases.1,5 This number is not significantly smaller and, in some studies, is equally comparable to the outcomes with partial first ray amputations, making partial first ray amputations difficult to exclude in amputation planning.
Appreciating that regardless of level, there is little difference in the percentage of partial foot amputations that require re-amputation opens the door to better understanding the potential success of a partial first ray amputation.
Dr. Hadi is a faculty member with the Louis Stokes Cleveland Veterans Administration. She is a Fellow of the American College of Foot and Ankle Surgeons.