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

   Further, after review of our studies, it may be in the patient’s best interest to get a referral to a more specialized diabetic foot center of excellence since the incidence of re-amputation is half of what results when the patient receives care in a community-based facility. The exact reason for this remains a matter for conjecture since the same multidisciplinary team members (i.e., internal medicine/endocrinologists, infectious disease, vascular surgery, nutritionists, etc.) are present in both settings studied. Further study to elucidate this apparent discrepancy (including non-hospital based private practitioner outcomes) is warranted.

   Given the stated goals of surgical intervention, one should not consider any level of amputation that results in the need for further ongoing treatment for re-ulceration with weekly clinical evaluations, local wound management and oral antibiotic therapy as a successful outcome even in the situation of initial healing. In addition to concerns over limb- and life-threatening infection developing, healthcare costs associated with repeated clinical debridement, wound dressings and oral antibiotics are high. Patient satisfaction in the setting of complicated and time consuming dressings and intolerance of prolonged oral antibiotic therapy is also poor.

   In light of this, one may consider a single definitive and predictable procedure (such as a primary transmetatarsal amputation) at the time of initial intervention to be more satisfactory to the patient overall.29 Proper patient education is required at the time of surgical consultation to allow for proper decision making in this regard. In addition, one should consider surgical correction of any related foot deformities, such as hammering of the lesser digits, to prevent future ulcerations.30,31

   Dr. Borkosky is a graduate with distinction of the Rearfoot/Ankle Surgery Residency at the Gundersen Health System in La Crosse, Wis. She is in private practice at the Palmetto Podiatry Group in Andersen, S.C. Dr. Borkosky is an Associate of the American College of Foot and Ankle Surgeons.

   Dr. Roukis is attending staff in the Department of Orthopaedics, Podiatry and Sports Medicine at Gundersen Healthcare System in La Crosse, Wis. He is the President-Elect and a Fellow of the American College of Foot and Ankle Surgeons.

References

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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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