Incidence of re-amputation following partial first ray amputation associated with diabetes mellitus and peripheral sensory neuropathy: a systematic review.

Diabetes mellitus with peripheral sensory neuropathy frequently results in forefoot ulceration. Ulceration at the first ray level tends to be recalcitrant to local wound care modalities and off-loading techniques. If healing does occur, ulcer recurrence is common. When infection develops, partial first ray amputation in an effort to preserve maximum foot length is often performed. However, the survivorship of partial first ray amputations in this patient population and associated re-amputation rate remain unknown. Therefore, in an effort to determine the actual re-amputation rate following any form of partial first ray amputation in patients with diabetes mellitus and peripheral neuropathy, the authors conducted a systematic review. Only studies involving any form of partial first ray amputation associated with diabetes mellitus and peripheral sensory neuropathy but without critical limb ischemia were included. Our search yielded a total of 24 references with 5 (20.8%) meeting our inclusion criteria involving 435 partial first ray amputations. The weighted mean age of patients was 59 years and the weighted mean follow-up was 26 months. The initial amputation level included the proximal phalanx base 167 (38.4%) times; first metatarsal head resection 96 (22.1%) times; first metatarsal-phalangeal joint disarticulation 53 (12.2%) times; first metatarsal mid-shaft 39 (9%) times; hallux fillet flap 32 (7.4%) times; first metatarsal base 29 (6.7%) times; and partial hallux 19 (4.4%) times. The incidence of re-amputation was 19.8% (86/435). The end stage, most proximal level, following re-amputation was an additional digit 32 (37.2%) times; transmetatarsal 28 (32.6%) times; below-knee 25 (29.1%) times; and LisFranc 1 (1.2%) time. The results of our systematic review reveal that one out of every five patients undergoing any version of a partial first ray amputation will eventually require more proximal re-amputation. These results reveal that partial first ray amputation for patients with diabetes and peripheral sensory neuropathy may not represent a durable, functional, or predictable foot-sparing amputation and that a more proximal amputation, such as a balanced transmetatarsal amputation, as the index amputation may be more beneficial to the patient. However, this remains a matter for conjecture due to the limited data available and, therefore, additional prospective investigations are warranted

Level of Amputation Following Failed Arterial Reconstruction Compared to Primary Amputation – a Meta-analysis

AbstractObjectives:to determine if the level of amputation after failed vascular reconstruction was comparable to the level of amputation after primary amputation.Design and methods:medline literature search (1975–1996), meta-analysis.Results:the odds ratio of transtibial to transfemoral (TT/TF) amputations was 927/657=1.41 (95% confidence limits: 1.278–1.561) in postrevascularisation amputation (PRVA) and 1590/1162=1.37 (95% confidence limits: 1.269–1.477) in primary amputation (PA) (p=0.65). The pooled data show that the number of conversions from transtibial (TT) to transfemoral (TF) amputations due to amputation stump complications were 85/369 (23%) in PRVA against 93/752 (12.4%) in PA (p<0.01).Conclusions:we could not detect any difference in TT/TF ratio between PRVA and PA. However, the risk of conversion i.e. reamputation to a higher level is higher after PRVA compared to PA. The chance of having a successful transtibial amputation is approximately 58% for postrevacularisation amputation as well as for primary amputations. An aggressive approach towards vascular reconstruction seems justified