Why Partial First Ray Amputations In Patients With Diabetic Neuropathy Do Not Work

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Author(s): 
Sara L. Borkosky, DPM, AACFAS, and Thomas S. Roukis, DPM, PhD, FACFAS

   The initial level of amputation is detailed in the chart at right. Healing of the surgical incision occurred in all 59 patients.5 However, 69 percent (41 patients) went on to develop a foot ulceration following the index amputation in a mean of only 10.5 months with an average of 3.1 ulcerations per patient. Additionally, 36 percent (21 patients) required ancillary surgical procedures. There was a mean of 26.6 clinical visits per patient from the time of initial amputation to when either complete healing had occurred with no further ulcerations or definitive re-amputation occurred. In addition, 92 percent of patients took prescription antibiotics postoperatively with a mean of 2.3 different antibiotics prescribed. Unfortunately, 25 (42.4 percent) patients had a more proximal re-amputation within a short mean of 25 months. Interestingly, the most common level of re-amputation did not occur more proximally within the first ray.

   Our data determined that in a community-based hospital setting, half of the patients with diabetes and peripheral sensory neuropathy undergoing any version of a partial first ray amputation will eventually require more proximal re-amputation.5 This data questions the reliability and durability of this level of amputation as a primary procedure in this patient population. Additionally, it does not seem fiscally sound.

Final Thoughts

The goal of any amputation is the complete eradication of non-viable tissue, optimizing the host’s healing potential while reducing the risk for further breakdown and the need for extended local wound care, specialized shoe gear or repeated surgical intervention.4 As we demonstrated in the aforementioned studies, a partial first ray amputation at any level in patients with diabetic neuropathy does not meet these goals in this high-risk population in which risk management is especially critical.4 Even a partial hallux amputation had the same potential for re-amputation as a near complete first ray amputation. This implies the significant role the first ray has in the function of the foot and limited tolerance for amputation at this level in insensate feet.

   As we noted in the second study, nearly half of these patients will require a more proximal level of re-amputation within a mean of 25 months. There was also a high mortality rate within this patient population with 48 percent of the patients deceased at a mean time of 34.6 months following the index amputation. While one may attribute this to the disease process itself, the mean age of included patients was only 67 years old. Due diligence is therefore required when evaluating the patient to determine the optimal level of initial amputation and may require a more proximal level.3-13

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Neil H Hecht DPMsays: October 15, 2013 at 12:14 pm

This is an interesting paper. However, I do take exception to the notion that sub-total 1st ray amputations "don't work." Of course, they work. The issue is highly patient dependent. Certainly, further amputations or revisions do occur and statistically this may exceed what would be acceptable in most scientific reviews.

However, two issues come to mind.

1) What would a "center of excellence" propose? TMA, Chopart disarticulation, or higher amputations to obviate any further foot procedures? (This is assuming that amputation of something is absolutely necessary. I work at two wound centers and certainly SOME recommended amputations can be avoided at times.)

2) Not all the patients fall into the study criteria. For example, my patient in the hospital right now had a sub-total first ray amputation with the 2nd toe disarticulation at the 2nd MTPJ due to overt gangrene, abscess and cellulitis, with a history of severe cardiomyopathy, CKD, s/p ilio-tib bypass, and poorly controlled type 2 diabetes without primary closure of the surgical site. He may have a year to live.

So the final point is sometimes a sub-total first ray amputation DOES work for the particular patient in mind. That's my problem with the title of the paper in that others may reject the necessary procedure.

Please e-mail me any desired response but I do appreciate your efforts in this study.

Fraternally,

Neil H Hecht, DPM, FACFAS, FACFAO

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Ira Weiner, DPMsays: October 17, 2013 at 12:14 pm

I currently am the assistant director of a wound care center/limb salvage program. I am called upon to perform partial first ray amputations on a regular basis. I would tend to believe that the destabilization of the forefoot and midfoot after the procedure leads to recurrence and re-amputation at a higher level.

For this reason, I have began "beaming" the remainder of the medial column. I have found initially this prevents the destabilization and further surgical intervention on the first ray and medial column. The patients are followed with a custom insole to help protect the area. Any additional procedures on the lesser digits can be performed assuming appropriate revascularization has been done if needed.

To date, this seems to result in a higher patient satisfaction than a primary transmetatarsal amputation

Cheers

Ira Weiner, DPM

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