Outcomes of toe amputation in patients with type 2 diabetes

NewsBot · Apr 21, 2016

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Clinical outcomes of toe amputation in patients with type 2 diabetes in Tianjin, China
Yue-Jie Chu, Xi-Wen Li, Peng-Hua Wang, Jun Xu, Hao-Jie Sun, Min Ding, Jiao Jiao, Xiao-Yan Ji andShu-hong Feng
International Wound Journal; Volume 13, Issue 2, pages 175?181, April 2016

The aim of this study is to determine the predictors for reulceration, reamputation and mortality in patients with diabetes following toe amputation, and the impact of activities of daily living on clinical outcomes.

This prospective cohort study included 245 patients who had undergone toe amputation (202 healing and 43 non-healing) and was followed for a 5-year period. Data regarding new foot ulceration, reamputation and mortality were recorded, and the patients' activities of daily living were evaluated.

The rate of wound healing was 82?4%. The rate of follow-up in the healed group was 91?6%. In years 1, 3 and 5, the cumulative incidence of patients who developed a new foot ulcer was 27?3%, 57?2% and 76?4%, respectively, leading to reamputation in 12?5%, 22?3% and 47?1%, respectively. The cumulative mortality was 5?8%, 15?1% and 32?7% at 1, 3 and 5 years, respectively. Multivariate analysis showed that GHbA1c > 9% (75 mmol/mol) was identified as an independent predictor of impaired wound healing, reulceration and reamputation. An age of >70 years was identified as an independent predictor of reamputation, mortality and impairment of activities of daily living.

Despite a satisfactory initial healing rate after the first toe amputation, with the extension course after the toe amputation, the long-term outcomes are not optimistic. In developing countries like China, taking measures to prevent reulceration and reamputation is very important for patients with diabetic foot minor amputations, especially following toe amputation.
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NewsBot · Oct 6, 2018

Modified Toe Amputation Reduces Hematoma Rate in Diabetic Foot Ulcer
Sooseong Leem, Jung Woo Chang, M. Seung Suk Choi
Journal of Wound Management and Research 2018; 14(2): 68-73.

Background
One of the common methods to perform toe amputation is the enucleation of the toe at the metatarsophalangeal joint. The level of the web space skin is far more distal than the amputation level; hence, a dead space is inevitably formed between the level of skin closure and the metatarsophalangeal joint, which is prone to hematoma formation. We describe a method to amputate the toe at the proximal phalanx, just proximal to the web space skin, that prevents dead space formation and potentially reduces the hematoma rate.
Methods
Eleven patients with diabetic foot ulcers had a toe amputation just proximal to the level of the web space skin. After creation of a small flap for closure, the proximal phalanx was amputated approximately 2–3 mm proximal to the level of the web space skin. The skin flap was closed in a primary or delayed fashion depending on the infection status. Two patients underwent the operation without discontinuing anti-platelet medication. Follow-up loss occurred in one case.
Results
None of the patients showed hematoma formation. One patient underwent additional amputation due to residual infection. All the other patients healed primarily without any additional revision or surgery of the amputated toe.
Conclusion
The described toe amputation technique at the level of the web space skin prevents dead space formation, which can occur after toe enucleation at the metatarsophalangeal joint, thus inhibits hematoma formation.
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NewsBot · May 7, 2019

Outcome of trans-metatarsal amputations in patients with diabetes mellitus.
Humphrey JA et al
Foot (Edinb). 2019 Apr 8;40:22-26

BACKGROUND:
This retrospective case series reports the reoperation rate, survival rate and mobility status in patients with diabetes mellitus who had undergone a trans-metatarsal amputation (TMA) managed within a diabetic foot care service.

METHODS:
Forty-one consecutive patients (37 men, 4 women) underwent a TMA with primary wound closure between January 2008 and December 2017. Eighty-eight per cent (36/41) of the patients were followed-up for a mean of 2.3 years. The outcomes were retrospectively reviewed.

RESULTS:
Four (11%) of the 36 patients required reoperation, including three (8%) major amputations. All of the patients requiring a reoperation had peripheral vascular disease. Eleven patients died giving a four-year survival rate of 69% (25/36). Of the surviving patients who had not required revision to a major amputation 96% (21/22) were fully mobile in bespoke orthoses. A third used a walking cane.

CONCLUSION:
This study shows that a TMA with primary wound closure in patients with diabetes mellitus, is effective for limb salvage with low reoperation and major amputation rates. A well healed TMA stump provides independent mobility in the majority of patients. The failures occurred in patients with peripheral vascular disease who, even after percutaneous trans-luminal angioplasty, had a 19% major amputation rate.
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NewsBot · Jul 14, 2022

Analysis of repeated lesions after diabetic forefoot amputation
Youngrak Choi et al
July 13, 2022

This study was performed to analyze the clinical characteristics, related factors, and prognosis of repeated lesions after diabetic forefoot amputation.
Methods
The medical records of 998 patients who underwent forefoot amputation because of their diabetic feet from March 2002 to February 2021 were retrospectively analyzed. Of the 508 selected patients with a follow-up period of at least 6 months, 288 had repeated lesions in the forefoot, and 220 did not have repeated lesions. The related factors of repeated lesions were compared and analyzed. Of the patients with repeated lesions, 142 and 104 on the ipsilateral and contralateral sides, respectively were also compared and examined.
Results
Repeated lesions were statistically significant in diabetic polyneuropathy, vascular calcification, and dialysis. However, the anatomical positions of diabetic foot lesions, causes of lesions, anatomical amputation levels, number of surgeries, and management duration had no significant differences. Contralateral lesions occurred 8 months later than ipsilateral lesions, but reamputation above the Lisfranc joint was more frequent and prognosis was poorer.
Conclusions
Repeated lesions were affected by general conditions, and the contralateral side must be carefully examined after diabetic forefoot amputation.
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NewsBot · Sep 8, 2022

Outcomes of Hallux Amputation Versus Partial First Ray Resection in People with Non-Healing Diabetic Foot Ulcers: A Pragmatic Observational Cohort Study
Virginie Blanchett et al
Int J Low Extrem Wounds. 2022 Sep 7

There are few data comparing outcomes after hallux amputation or partial first ray resection after diabetic foot ulcer (DFU). In a similar context, the choice to perform one of these two surgeries is attributable to clinician preference based on experience and characteristics of the patient and the DFU. Therefore, the purpose of this study was to determine the more definitive surgery between hallux amputation and partial first ray resection. We abstracted data from a cohort of 70 patients followed for a 1-year postoperative period to support clinical practice. We also attempted to identify patient characteristics leading to these outcomes. Our results suggested no statistical difference between the type of surgery and outcomes such as recurrence of DFU and amputation at 3, 6, and 12 months or death. However, there was a statistically significantly increased likelihood of re-ulceration for patients with CAD who underwent hallux amputation (p = 0.02). There was also a significantly increased likelihood of re-ulceration for people with depression or a history when the partial ray resection was performed (p = 0.02). Patients with prior amputation showed a higher probability of undergoing another re-amputation with partial ray resection (p = 0.01). Although the trends that emerge from this project are limited to what is observed in this statistical context, where the number of patients included and the number of total observations per outcome were limited, it highlights interesting data for future research to inform clinical decisions to support best practices for the benefit of patients.
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NewsBot · Feb 14, 2023

Ulcer occurrence on adjacent toes and hallux valgus deformity after amputation of the second toe in diabetic patients
Ines Unterfrauner et al
J Orthop Surg Res. 2023 Feb 13;18(1):99. doi: 10.1186/s13018-023-03577-z.

Background: Amputation of the second toe is associated with destabilization of the first toe. Possible consequences are hallux valgus deformity and subsequent pressure ulcers on the lateral side of the first or on the medial side of the third toe. The aim of this study was to investigate the incidence and possible influencing factors of interdigital ulcer development and hallux valgus deformity after second toe amputation.

Methods: Twenty-four cases of amputation of the second toe between 2004 and 2020 (mean age 68 ± 12 years; 79% males) were included with a mean follow-up of 36 ± 15 months. Ulcer development on the first, third, or fourth toe after amputation, the body mass index (BMI) and the amputation level (toe exarticulation versus transmetatarsal amputation) were recorded. Pre- and postoperative foot radiographs were evaluated for the shape of the first metatarsal head (round, flat, chevron-type), the hallux valgus angle, the first-second intermetatarsal angle, the distal metatarsal articular angle and the hallux valgus interphalangeal angle by two orthopedic surgeons for interobserver reliability.

Results: After amputation of the second toe, the interdigital ulcer rate on the adjacent toes was 50% and the postoperative hallux valgus rate was 71%. Neither the presence of hallux valgus deformity itself (r = .19, p = .37), nor the BMI (r = .09, p = .68), the shape of the first metatarsal head (r = - .09, p = .67), or the amputation level (r = .09, p = .69) was significantly correlated with ulcer development. The interobserver reliability of radiographic measurements was high, oscillating between 0.978 (p = .01) and 0.999 (p = .01).

Conclusions: The interdigital ulcer rate on the first or third toe after second toe amputation was 50% and hallux valgus development was high. To date, evidence on influencing factors is lacking and this study could not identify parameters such as the BMI, the shape of the first metatarsal head or the amputation level as risk factors for the development of either hallux valgus deformity or ulcer occurrence after second toe amputation.
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NewsBot · Apr 3, 2023

Long term functional outcomes of hallux amputations at various anatomic levels
Amish Dudeja, DPM et al
March 16, 2023

Purpose
Hallux amputations have long been used for treatment of hallux osteomyelitis as a result of ulcerations at various levels of the hallux. The aim of this study is to expand on a previously presented poster and to assess the long-term functional outcomes in patients with various levels of hallux amputations and determine whether there is an ideal anatomic level that will limit the amount of post-operative complications.
Methodology and procedure
A retrospective review of 148 feet with hallux amputations performed at various levels from 7/1/2013 to 7/16/2020 was performed. Two years minimum follow up was required for inclusion in the study. Re-ulceration, further amputation, healing of index procedure, and revascularization status were evaluated. Statistical analysis utilizing chi square analysis was performed to calculate p values where <0.05 was statistically significant.
Results
A tendency for amputations performed at the level of the head of the proximal phalanx (67%) or at the metatarsophalangeal joint (52%) to have less re-ulceration rates.
Analysis and discussion
Although partial hallux amputations have historically been considered more successful than full hallux amputations, our study shows that there is no statistically significant difference between levels of hallux amputations, particularly when looking at re ulceration rates.
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NewsBot · May 1, 2023

Long term functional outcomes of hallux amputations at various anatomic levels
Amish Dudeja, DPM et al
Source

Purpose
Hallux amputations have long been used for treatment of hallux osteomyelitis as a result of ulcerations at various levels of the hallux. The aim of this study is to expand on a previously presented poster and to assess the long-term functional outcomes in patients with various levels of hallux amputations and determine whether there is an ideal anatomic level that will limit the amount of post-operative complications.
Methodology and procedure
A retrospective review of 148 feet with hallux amputations performed at various levels from 7/1/2013 to 7/16/2020 was performed. Two years minimum follow up was required for inclusion in the study. Re-ulceration, further amputation, healing of index procedure, and revascularization status were evaluated. Statistical analysis utilizing chi square analysis was performed to calculate p values where <0.05 was statistically significant.
Results
A tendency for amputations performed at the level of the head of the proximal phalanx (67%) or at the metatarsophalangeal joint (52%) to have less re-ulceration rates.
Analysis and discussion
Although partial hallux amputations have historically been considered more successful than full hallux amputations, our study shows that there is no statistically significant difference between levels of hallux amputations, particularly when looking at re ulceration rates.
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NewsBot · May 2, 2023

Epidemiology and Outcome of Nontraumatic Lower Limb Amputations
Muhammad Saaiq
Med J Islam Repub Iran. 2023 Mar 7;37:18

Background: In order to create a solid evidence base for the development of improved management methods, this study was performed to describe the epidemiology and outcome of nontraumatic lower limb amputations (LLAs).

Methods: This descriptive case series was conducted over a period of 4 years. It included all patients of both sexes and all ages who underwent LLAs for nontraumatic indications.

Results: There were a total of 217 patients with 136 (62.67%) men and 81(37.32%) women. The age range was 7 to 71 years, with a mean of 54.25 ± 11.49 years. The most common indication for amputation (41.47%) was diabetic foot gangrene. The most common level of amputation (48.29%) was below knee amputation.

Conclusion: Patients with diabetic foot gangrene, malignant tumors, and chronic neuropathic ulcers with osteomyelitis constituted the bulk of the amputees. Diabetes mellitus, obesity, and hypertension were the commonest comorbidities identified among them. Public awareness and education would ensure prompt and early health seeking at the appropriate time and help to prevent the need for major amputations in many instances. The amputees' improved reintegration into society and ability to become contributing members of society would be ensured by the provision of vigorous rehabilitation.
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NewsBot · May 29, 2023

Outcomes after minor lower limb amputation for peripheral arterial disease and diabetes: population-based cohort study
Panagiota Birmpili et al
Br J Surg. 2023 May 22

Background: Patients with diabetes and peripheral arterial disease are at increased risk of minor amputation. The aim of study was to assess the rate of re-amputations and death after an initial minor amputation, and to identify associated risk factors.

Methods: Data on all patients aged 40 years and over with diabetes and/or peripheral arterial disease, who underwent minor amputation between January 2014 and December 2018, were extracted from Hospital Episode Statistics. Patients who had bilateral index procedures or an amputation in the 3 years before the study were excluded. Primary outcomes were ipsilateral major amputation and death after the index minor amputation. Secondary outcomes were ipsilateral minor re-amputations, and contralateral minor and major amputations.

Results: In this study of 22 118 patients, 16 808 (76.0 per cent) were men and 18 473 (83.5 per cent) had diabetes. At 1 year after minor amputation, the estimated ipsilateral major amputation rate was 10.7 (95 per cent c.i. 10.3 to 11.1) per cent. Factors associated with a higher risk of ipsilateral major amputation included male sex, severe frailty, diagnosis of gangrene, emergency admission, foot amputation (compared with toe amputation), and previous or concurrent revascularization. The estimated mortality rate was 17.2 (16.7 to 17.7) per cent at 1 year and 49.4 (48.6 to 50.1) per cent at 5 years after minor amputation. Older age, severe frailty, comorbidity, gangrene, and emergency admission were associated with a significantly higher mortality risk.

Conclusion: Minor amputations were associated with a high risk of major amputation and death. One in 10 patients had an ipsilateral major amputation within the first year after minor amputation and half had died by 5 years.
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NewsBot · Aug 12, 2023

Predictors of Ambulatory Status at 1 Year Following Major Lower Extremity Amputation
Alexandra Forsyth, MD et al
June 30, 2023

Nearly 60,000 major lower extremity amputations (AKA/BKA) are performed annually in the United States. We created a simple risk score for predicting ambulation at 1 year following AKA/BKA. We queried the Vascular Quality Initiative amputation database for patients who underwent above-knee (AKA) or below-knee (BKA) amputation (2013-2018). The primary endpoint was ambulation at 1 year either independently or with assistance. The cohort was divided into 80% derivation and 20% validation. Using the derivation set, a multivariable model identified preoperatively available independent predictors of 1 year ambulation and an integer-based risk-score was created. Scores were calculated to assign patients to risk groups—low, medium, or high chance of being ambulatory at 1 year. Internal validation was performed by applying the risk score to the validation set. Of 8725 AKA/BKA, 2055 met inclusion criteria—excluded: 2644 nonambulatory prior to amputation, 3753 missing 1-year follow-up ambulatory status. The majority—n = 1366, 66% were BKAs. The indications were CLTI; 47%, ischemic tissue loss; 9%, ischemic rest pain; 35%, infection/neuropathic; 9%, acute limb ischemia. Ambulation at 1 year was higher for BKA than AKA: 67%, versus 50%, p < .0001. In the final prediction model, contralateral BKA/AKA was the strongest predictor of nonambulation. The score provided reasonable discrimination (C-statistic = 0.65) and was well calibrated (Hosmer-Lemeshow p = .24). Sixty-two percent of patients who were ambulatory preoperatively remained ambulatory at 1 year. An integer-based risk score can stratify patients according to chance of ambulation at 1 year after major amputation and may be useful for preoperative patient counseling and selection.
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NewsBot · Nov 2, 2023

Risk Factors Associated with Failure of Toe Amputation in Diabetic Foot Infections
Gerardo Víquez-Molina et al
Int J Low Extrem Wounds. 2023 Oct 26

We aim to identify the factors associated with the failure of amputation of one to three toes (index toe amputation) in patients with diabetes and foot infection. We conducted a retrospective cohort of 175 patients with diabetes who were hospitalized for moderate to severe foot infection and underwent amputation of one to three toes. A Poisson regression model was used to determine the prevalence ratio (PR) as a measure of association. The mean age was 63.3 ± 11.4 years. Fifty-three patients presented failure after undergoing toe amputation (30.3%). Multivariate analysis, adjusted for age and sex, showed the following significant variables: severe infection (PR: 1.78; 95% confidence interval [CI]: 1.14-2.78; P = 0.011), infection by Escherichia coli (PR: 2.21; 95% CI: 1.42-3.43; P < 0.001), infection by Pseudomonas aeruginosa (PR: 2.11; 95% CI: 1.29-3.43; P = 0.003) and prothrombin time (PR: 1.13; 95% CI: 1.05-1.21; P = 0.001), obesity (PR: 0.58; 95% CI: 0.37-0.93; P = 0.024), and haemoglobin value (PR: 0.92; 95% CI: 0.86-0.99; P = 0.023). About one-third of patients who underwent amputation of one to three toes for diabetic foot infection presented a failure and required a more proximal surgery. Severe infections, isolation of Pseudomonas aeruginosa and Escherichia coli, and prolonged prothrombin time were associated with a higher prevalence of failure. However, obesity and an elevated haemoglobin level were associated with a lower prevalence of failure.
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NewsBot · Apr 16, 2024

Second Metatarsal Length and Transfer Ulcers After First Metatarsal Amputation in Diabetic Foot Infections
Nicola A Cavalcanti et al
Foot Ankle Int. 2024 Mar 18

Background: Plantar transfer ulcers (TUs) underneath the second metatarsal head are frequent after first metatarsal ray amputations due to diabetic foot infections. Whether the second metatarsal length (2ML) is associated with TU occurrence in these patients is unclear. This study evaluated whether 2ML is associated with TU occurrence after first-ray amputations and whether ulcer-free survival is shorter in patients with "excess" 2ML.

Methods: Forty-two patients with a mean age of 67 (range 33-93) years, diabetes, and first metatarsal ray amputation (first amputation at the affected foot) were included. Two independent readers measured the 2ML using the Coughlin method. A protrusion of more than 4.0 mm of the second metatarsal was defined as "excess" 2ML. The effect of 2ML on ulcer occurrence was analyzed using a multivariate Cox regression model. A Kaplan-Meier curve for TU-free survival was constructed comparing the 2 groups of "normal" (n = 21) and "excess" 2ML (n = 21).

Results: Interrater reliability was excellent. TUs underneath the second metatarsal occurred in 15 (36%) patients. In agreement with our hypothesis, 2ML was nonsignificantly different in patients with TUs, recording a mean of 5.3 (SD 2.5) mm, compared to patients without 4.0 (SD 2.3) mm (hazard ratio [HR] 1.12, 95% CI 0.89-1.41), whereas insulin dependence was associated with ulcer occurrence (HR 0.33, 95% CI 0.11-0.99).

Conclusion: In our relatively small study population with a cutoff level of 4 mm for excess 2ML, ulcer-free survival was similar in patients with "normal" and "excess" 2ML.
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