SLR - July 2019 - Steven L. Stuto

Is Reconstruction Preserving the First Ray or First Two Rays Better Than Full Transmetatarsal Amputation in Diabetic Foot?

Suh, Y. C., Kushida-Contreras, B. H., Suh, H. P. et al. Is Reconstruction Preserving the First Ray or First Two Rays Better Than Full Transmetatarsal Amputation in Diabetic Foot? Plastic and Reconstructive Surgery, 143(1), 294-305.

Scientific Literature Review

Reviewed By: Steven L. Stuto, DPM
Residency Program: University Hospital – Newark NJ

Podiatric Relevance: Transmetatarsal Amputation is an effective surgical approach to limb preservation while treating forefoot infection, gangrene, and chronic ulceration in diabetic and ischemic patients. Not all forefoot diabetic foot ulcers are salvageable by a transmetatarsal amputation (TMA). Free flaps can be used to cover the defects and maximize the benefits after transmetatarsal amputations.

Methods: This article is a level three retrospective study based in Seoul, Republic of Korea from 2005-2016. Patients were divided into two groups: 1) Transmetatarsal amputation group, with total arc-shaped transmetatarsal amputation and 2) Flap reconstruction with first ray or first two ray preserving TMA.  

Results: There were total of 59 patients (TMA group, 27 patients; ray group, 32 patients), with 31 male and 28 female patients. The only significant factor was preoperative glucose level, which was higher in the ray group com-pared with the TMA group. The anterolateral thigh flap was the most frequently used for the TMA group, whereas the superficial circumflex iliac artery perforator flap was the most frequently used for the ray group. Flap failure rate was similar in the two groups: 11 percent and 16 percent. There was a higher rate of partial flap loss in the TMA group (30 percent) compared with the ray group (19 percent) but the difference was not statistically significant. Time to begin partial weight bearing was similar in both groups at approximately two weeks. During the first year of follow up the major procedure rate of the ipsilateral reconstructed limb was 15 percent in the TMA amputation and 3 percent in the ray group.

Conclusions: The study was able to conclude that the preservation of the first ray or first two rays with free flap re-construction may functionally benefit patients despite the higher tendency of minor procedures after initial healing and progressive deformity of the preserved rays requiring further surgery. They also believed that when the first ray is preserved, the inequality of surface area and force distribution is reduced in the ray group, allowing a better functional ambulation. However, given the high rate of ulcer recurrence, the total arc-shaped transmetatarsal amputation is preferred over ray amputation. 

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