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

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

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Comments

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

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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