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

Background: The benefits of total transmetatarsal amputation over higher level amputation are well known. However, there are no studies evaluating the effects of first ray- or first two ray-sparing transmetatarsal amputation with flap coverage. The authors evaluated this approach with regard to functional outcome and to identify long-term complications.

Methods: Retrospective data of 59 patients were evaluated according to their surgical method. Complete transmetatarsal amputation with free flap reconstruction was designated as the transmetatarsal amputation group with 27 patients and first ray- or first two ray-preserving transmetatarsal amputation with free flap reconstruction was designated as the ray group, with 32 patients. Demographics, flap outcomes, additional procedures after initial healing, and functional outcomes were measured and evaluated.

Results: There was no statistically significant difference in demographic distribution and flap outcomes in either group, except for poor blood glucose control in the ray group. Additional procedures after initial healing showed no statistical difference, but the tendency of minor procedures was higher in the ray group. The maximum achieved ambulatory function was significantly better in the ray group, with an ambulatory function score of 4.4 compared with 3.7 in the transmetatarsal amputation group (p = 0.012).

Conclusions: The preservation of the first ray or first two rays with free flap reconstruction may functionally benefit the patients despite the higher tendency toward minor procedures after initial healing. Furthermore, the progressive deformity of the preserved first and second toes will inevitably occur, requiring patients to undergo further surgery. Further studies are warranted to evaluate this approach.

Clinical Question/level Of Evidence: Therapeutic, III.