Digital amputations

Reviving the debate: Articular cartilage preservation during disarticulation at the lower limb? A systematic review

BACKGROUND

The need for preservation(P) or removal(R) of articular cartilage during disarticulations remains unanswered.

METHODS

Medline database was used to conduct a systematic review regarding all types of minor disarticulations and some types of major disarticulations in patients with diabetes mellitus, peripheral arterial disease or trauma related disarticulations. Fisher-exact statistical test was used to perform calculations for the entire group as for subgroups.

RESULTS

A total of 444 disarticulations at the Chopart joint, ankle and knee were included (P = 255 vs. R = 189). There was no difference in wound healing, functionality and mortality. Reamputation rate was lower in the P-group (9.4% vs. 16.9%). Infection rate was not significantly different. Differences in reamputations (R = 10.6% vs. P = 1.0%) and infections (R = 4.4% vs. P = 22.6%) were only present for the ankle subgroup.

CONCLUSIONS

There is no difference in wound healing, functionality and mortality between the preservation and removal of articular cartilage in the lower limb.

In-office distal Symes lesser toe amputation: a safe, reliable, and cost-effective treatment of diabetes-related tip of toe ulcers complicated by osteomyelitis

Diabetes-related tip of lesser toe ulcers have typically been associated with both underlying hammertoe contracture and peripheral neuropathy. The combination of digital deformity and neuropathy commonly results in non-healing, deep sores that frequently become complicated by osteomyelitis. We report on a well-known, but poorly reported, technique for surgical management of non-healing tip of lesser toe ulcers. After approval by the institutional review board, a review was performed of consecutive patients who had undergone office-based distal Symes toe amputation for a non-healing tip of lesser toe ulcer from January 2007 to December 2012. A variety of clinical, laboratory, and radiographic data were collected. A total of 48 consecutive patients (48 toe ulcers) were identified for inclusion in the present study. All patients had ulcers at the time of surgery, and no patient developed repeat ulceration of the involved digit postoperatively. Of the 48 patients, 44 (92%) had hammertoe deformity preoperatively. Also, 30 patients (63%) had positive probe-to-bone results, and 29 (97%) of these patients had culture or histologic findings positive for osteomyelitis. Of the 48 patients (48 ulcers), 73% had positive bone cultures, 69% had positive pathologic findings demonstrating osteomyelitis, and 100% had clean margins. Methicillin-resistant Staphylococcus epidermidis was the most common pathogen isolated (13 of 48, 27%). No patient required additional amputation related to the operative digit. The mean follow-up period was 28.79 months. Our results have shown that in-office distal Symes lesser toe amputation is a safe, reliable, and likely cost-effective treatment of non-healing tip of lesser toe ulcers complicated by osteomyelitis. This office-based procedure allows bone biopsy diagnosis, removes the non-healing ulcer, confirms clear margins regarding the osteomyelitis, and addresses the underlying toe deformity to minimize the chances of repeat ulceration.

Partial foot amputations for salvage of the diabetic lower extremity

Lower extremity infections are a common yet unfortunate complication of diabetes-related ulcers often requiring surgical intervention. The main goals of surgical treatment consist of selecting the appropriate procedure to effectively eradicate nonsalvageable tissue, achieve primary healing, and maximize subsequent dynamic functionality. An overview of each partial foot amputation procedure is discussed with a focus on procedure selection as well as standard and advanced surgical techniques. The effective application of partial foot amputations in the high-risk diabetic population can act to minimize the need for major proximal lower limb amputations.

Minimum-incision ray resection

Ray resection for localized necrosis, infection, and osteomyelitis is an accepted procedure allowing removal of the diseased toe and metatarsal. The traditional approach involves a rather lengthy incision and dissection that can compromise the vascular supply to the remaining forefoot. The use of minimum incision techniques to perform metatarsal ray resection as presented here represents a simple, reliable, and easily reproduced procedure that limits soft-tissue dissection and the associated wound healing-related complications inherent to the traditional approach. Following minimum incision metatarsal ray resection, the resultant defect from the toe amputation can be primarily closed, covered with a split-thickness skin graft, or closed in delayed primary fashion with the use of a mini-external fixation device. The authors present the proper indications and a step-by-step guide for performing minimum incision metatarsal ray resection with and without the supplemental use of mini-external fixation to close the soft-tissue defect about the toe amputation site.