• 1

    American Diabetes Association: Statistics about diabetes. Available at: http://www.diabetes.org/resources/statistics/statistics-about-diabetes. Accessed April 3, 2020.

    • Search Google Scholar
    • Export Citation
  • 2

    Adler AI, Boyko EJ, Ahroni JH, et al.: Lower-extremity amputation in diabetes: the independent effects of peripheral vascular disease, sensory neuropathy, and foot ulcers. Diabetes Care 22: 1029, 1999.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Zhang P, Lu J, Jing Y, et al.: Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis. Ann Med 49: 106, 2016.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 4

    Fu XL, Ding H, Miao WW, et al.: Global recurrence rates in diabetic foot ulcers: a systematic review and meta‐analysis. Diabetes Metab Res Rev 35: e3160, 2019.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 5

    Yazdanpanah L, Nasiri M, Adarvishi S: Literature review on the management of diabetic foot ulcer. World J Diabetes 6: 37, 2015.

  • 6

    Leone S, Pascale R, Vitale M, et al.: Epidemiology of diabetic foot. Infez Med 20(suppl 1): 8, 2012.

  • 7

    Kadukammakal J, Yau S, Urbas W: Assessment of partial first-ray resections and their tendency to progress to transmetatarsal amputations: a retrospective study. JAPMA 102: 412, 2012.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8

    Borkosky SL, Roukis TS: Why partial first ray amputations in patients with diabetic neuropathy do not work. Podiatry Today Web site. Available at: www.podiatrytoday.com/why-partial-first-ray-amputations-patients-diabetic-neuropathy-do-not-work. Accessed April 5, 2020.

    • Search Google Scholar
    • Export Citation
  • 9

    Borkosky SL, Roukis TS: Incidence of re-amputation following partial first ray amputation associated with diabetes mellitus and peripheral sensory neuropathy: a systematic review. Diabet Foot Ankle 3: 12169, 2012.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10

    Johnson MK, Rybczynski J, Kanat IO: Hallux amputation for diabetic osteomyelitis. J Foot Surg 26: 141, 1987.

  • 11

    Aprile, I, Galli M, Pitocco D, et al.: Does first ray amputation in diabetic patients influence gait and quality of life? J Foot Ankle Surg 57: 44, 2018.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 12

    Waters RL, Perry J, Antonelli D, et al.: Energy cost of walking of amputees: the influence of level of amputation. J Bone Joint Surg Am 58: 42, 1976.

  • 13

    Sinha R, van den Heuvel WJ, Arokiasamy P: Factors affecting quality of life in lower limb amputees. Prosthet Orthot Int 35: 90, 2011.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 14

    Lavery LA, Lavery DC, Quebedeax-Farnham TL: Increased foot pressures after great toe amputation in diabetes. Diabetes Care 18: 1460, 1995.

  • 15

    Dalla Paola L, Faglia E, Caminiti M, et al.: Ulcer recurrence following first ray amputation in diabetic patients: a cohort prospective study. Diabetes Care 26: 1874, 2003.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Armstrong DG, Lavery LA, Harkless LB, et al.: Amputation and reamputation of the diabetic Foot. JAPMA 87: 255, 1997.

  • 17

    Molines-Barroso RJ, Lazaro Martinez JL, Aragon Sanchez J, et al.: The influence of the length of the first metatarsal on the risk of reulceration in the feet of patients with diabetes. Int J Low Extrem Wounds 13: 27, 2013.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 18

    Borkosky SL, Roukis TS: Incidence of repeat amputation after partial first ray amputation associated with diabetes mellitus and peripheral neuropathy: an 11-year review. J Foot Ankle Surg 52: 335, 2013.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 19

    Van Damme H, Rorive M, Martens De Noorthout B, et al.: Amputations in diabetes patients: a plea for foot sparing surgery. Acta Chir Belg 101: 1239, 2001.

    • Search Google Scholar
    • Export Citation
  • 20

    Izumi Y, Satterfield K, Lee S, et al.: Risk of reamputation in diabetic patients stratified by limb and level of amputation: a 10-year observation. Diabetes Care 29: 566, 2006.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Murdoch DP, Armstrong DG, Dacus JB, et al.: The natural history of great toe amputations. J Foot Ankle Surg 36: 204, 1997.

  • 22

    Greenhagen RM, Johnson AR, Bevilacqua NJ: Smoking cessation: the role of the foot and ankle surgeon. Foot Ankle Spec 3: 21, 2010.

  • 23

    Anderson JJ, Boone J, Hansen M, et al.: A comparison of diabetic smokers and non-smokers who undergo lower extremity amputation: a retrospective review of 112 patients. Diabet Foot Ankle 3: 19178, 2012.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 24

    Xia N, Morteza A, Yang F, et al.: Review of the role of cigarette smoking in diabetic foot. J Diabetes Investig 10: 202, 2019.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation

Metatarsal Protrusion Distance and Its Influence on Recurrent Ulceration Rates After Partial First-Ray Amputations: A Retrospective Study

View More View Less
  • 1 Podiatric Medicine and Surgery Residency Program, Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC.
  • | 2 Lower Extremity Limb Salvage/Trauma, University of Pittsburgh Medical Center, Pittsburgh, PA.
  • | 3 Wake Forest Baptist Medical Center, Winston-Salem, NC.
  • | 4 Podiatric Medicine and Surgery Residency, Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC.
Restricted access

Background: Recurrent ulceration is a common problem after partial first-ray amputations. Loss of the first metatarsophalangeal joint contributes to altered biomechanics and increased pressure on the foot. This may increase risk of adjacent ulcerations and additional amputations. Preserving first-ray length maintains the metatarsal parabola and limits transfer lesions, but few data support this. We aimed to evaluate the incidence of ulceration after partial first-ray amputations and to assess the association between metatarsal protrusion distance and recurrent ulceration.

Methods: Thirty-two consecutive patients underwent unilateral partial first-ray amputation at various levels along the first metatarsal, and the metatarsal protrusion distance was measured after surgery. Incidence of ulceration was evaluated on the ipsilateral foot. We hypothesized that patients with a longer first metatarsal were less likely to ulcerate again on the ipsilateral foot.

Results: Fourteen patients (43.8%) ulcerated again after partial first-ray amputation. Mean time to ulceration was 104 days. Active smoking status was associated with increased risk of another ulceration (P = .02), and chronic kidney disease was associated with a decreased risk of recurrent ulceration (P = .03). The average metatarsal protrusion distance for patients who ulcerated again after surgery was 36.1 mm versus 25.9 mm for patients who did not (P = .04). Logistic regression analysis of the receiver operating characteristic curve demonstrated an ideal cutoff length for recurrent ulceration of 37 mm (area under the curve = 0.7381). Patients with a protrusion distance greater than 37 mm were nine times as likely to ulcerate again (95% CI, 1.7–47.0).

Conclusions: Partial first-ray amputations can be a good initial salvage procedure to clear infection and prolong bipedal ambulatory status. Unfortunately, these patients are prone to recurrent ulceration. Significant loss of first metatarsal length is a poor prognostic indicator for recurrent ulceration.

Corresponding author: Hayden L. Hoffler, DPM, Podiatric Medicine and Surgery Residency Program, Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, 2150 Country Club Rd, Ste 100, Winston-Salem, NC 27104. (E-mail: hhoffler@wakehealth.edu)