Toe amputation: a predictor of future limb loss?

Background: Digital toe amputation is a relatively minor surgical procedure but there is a historical view that it is the "first stage in a predictable clinical course" leading to eventual limb loss. There is a paucity of contemporaneous data on the long-term outcomes of patients undergoing toe amputation. We aim to study the experience from our institution, focussing on the risk factors for progression to future limb loss, by conducting a retrospective review of our practice.

Methods: Sixty-three patients undergoing toe amputation within our institution were identified and the clinical notes retrospectively reviewed. A database of vascular risk factors and co-morbidity was constructed and correlation with future limb loss was analysed with Chi-squared testing and a logistic regression model.

Results: Sixty-three patients with a mean age of 69 (IQR 62-76.5) years were identified. Thirty-five (55.6%) of these patients went on to have a further surgical amputation; 22 major amputations (16 below-knee and 6 above-knee amputations) and 23 minor amputations were performed in total. Forty three (68.3%) patients had diabetes and 31 (49.2%) patients had one or more revascularisation procedures undertaken. There was a significant correlation between patients who did not have diabetes and future limb loss (Chi-squared=4.31, p=0.038), however no other identified risk factor predicted the need for major amputation.

Conclusion: Toe amputation is a significant predictor of future limb loss. Our study identified that patients with diabetes are significantly less likely to progress to further limb loss than those with the disease. We hypothesise that this difference is due to the more intensive, multi-disciplinary foot care follow-up that diabetic patients receive. These results highlight the significance of toe amputation and contribute to the evidence for a more intensive out-patient service for these high risk patients.