Section: CME Category: Surgery

Ray Amputations

Jaclyn Marino, DPM, MPH, PhD

Jaclyn Marino, DPM, PhD, MPH discusses the evaluation and surgical techniques for distal and proximal ray amputations.

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Goals and Objectives
  1. Understand the who, what, where, why, and how of ray amputations
  2. Describe surgical techniques for ray amputations
  3. Describe the value of distal vs proximal ray amputations in the patient population
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    Release Date: 04/26/2018 Expiration Date: 12/31/2020

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  • It is the policy of PRESENT e-Learning Systems and it's accreditors to insure balance, independence, objectivity and scientific rigor in all its individually sponsored or jointly sponsored educational programs. All faculty participating in any PRESENT e-Learning Systems sponsored programs are expected to disclose to the program audience any real or apparent conflict(s) of interest that may have a direct bearing on the subject matter of the continuing education program. This pertains to relationships with pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject matter of the presentation topic. The intent of this policy is not to prevent a speaker with a potential conflict of interest from making a presentation. It is merely intended that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts.

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    Jaclyn Marino has nothing to disclose.

  • Lecture Transcript
  • TAPE STARTS – [00:00]


    Frykberg: Okay. Our next topic will be ray amputations. And so as for toe amputations, ray amputations are exceedingly common and not the easiest, not the easiest to recover from because there are many complications.

    So speaking about complications for ray amputations, I can’t think of nobody other than my colleague, Dr. Jacqueline Marino. Dr. Marino trained in the Miami VA and she finished her three years there and she came to us three years ago and she’s been a welcomed blessing to our unit and our programs. So, let’s welcome Dr. Jacqueline Marino.

    You should have sat in the front.

    [OFF-MIC]

    Okay. There you go.

    Jacqueline Marino: Okay, thank you. Good morning. I just want to say that it’s an honor to talk to you all.

    [OFF-MIC]

    Thank you. [Laughs] Thanks to Dr. Frykberg for this opportunity to talk to you all and for this amazing conference. It was really great again this year.

    I am the Assistant Residency Director at the Phoenix VA, under Dr. Frykberg, and I’m also an Attending Surgical Podiatrist there. And I’m speaking today about ray amputations with -- which is something that we do often. And if you were at the VA, I’m sure you do it often, too.

    My talk today is going to serve as just a refresher. It’s a reminder of the literature, what the numbers are, what they mean to us, what they mean to your patients, how to convey that information to your patients in a meaningful way and to their families who have to deal with the secondary issues that come from ray amputations.

    [2:00]

    And also, a very small surgical refresher for those of you that are starting to this again in your practice locally.

    Okay. My disclosures. I don’t have any relevant disclosures for this. So that’s pretty simple.

    What are our objectives today? It’s to understand the who, what, where, when -- oh, sorry. Who, what, where, why, and how of ray amputations. What populations they tend to affect, are there any differences among populations, why do people need ray amputations, and what are the preliminary pathology that might lead to ray resection, and basically how to deal with them, the surgical technique I talked about, and understanding the value of distal versus proximal ray amputations. This is very important. It’s -- there’s evidence-based medicine to support that you want to do a more distal procedure versus the proximal amputation and we’ll kind of get into that and why that’s important.

    So we start with the five Ws and one H about the problem. Who tends to need ray resections? What are the causative factors? When does biomechanics play a role? I found in my literature review that there are actually global differences among some populations. I’m going to touch on that in terms of the why. I like to look at predictors, who will do well and who will progress to a higher-level amputation, and how will we increase survivability so that we can avoid higher-level amputations all together.

    Because we know the value of distal foot salvage, they’re better than proximal amps. Thirty years ago, we only had below knee amputations. So we really have progressed to better procedures for limb salvage and ray amputations are one of those procedures. So we’re going to act like a detective and answer some key questions regarding ray amputations.

    So to set the stage, what are we talking about? One of the real problems is the overburden, of course, of our healthcare system financially and morbidity and mortality of patients.

    [4:05]

    This is a really well-known study, the Dillingham study, looking at one year’s worth of Medicare data. It’s an older study but it’s a good one. They actually had all kinds of data in there, toe, ray, mid-foot proximal, but I kind of pulled the ray data out of this, and you can see that, you know, back, I guess in 2005, average cost was 45,000 per year, I’m sure there are better numbers on this, but it’s just to set the stage of what we’re dealing with in the cost realm. But mainly who do ray amputations affect? And they’re the highest among men, racial minorities, and then you can see that recidivism is a factor.

    There is almost a quarter, 25% reamputation rate among diabetics with a toe level amputation already, and more than 40% of those actually results in a transtibial amputation. So that’s pretty significant. We’re going to start to see numbers, a lot of numbers, but I’m going to try to explain them to you in a meaningful way.

    And I think one of the important things to understand is even after you do a toe, a digital amputation, or even a ray amputation, the same risk factors are still present in that patient. They still have neuropathy, they still have deformity. Sometimes, of course, doing the surgery can cause a new deformity, and you can have more amputations down the road. So I really like this study.

    Mainly one in four patients who undergo ray amputations will have that transtibial, I think that’s the take home here, and I like the last bullet which is the same thing, like I don’t know if it’s Dr. Phil or Oprah, they always say the best indicator of future behavior is past behavior. The previous amputations are strong predicators of future amputations. So I think that’s important to understand.

    This slide speaks to ethnicity and access.

    [6:00]

    In the United States, African-Americans have the twice the excess risk for lower extremity amputations compared to Whites. But if you look in the UK, Caribbeans of African descent have a third lower risk than Europeans in London, which is interesting. But if you look at the same Afro-Caribbean group in the Caribbean, their lower extremity amputation rates are overall similar to that of the US. And I think that this speaks to the multifactorial component involved in lower extremity amputation.

    There may be a genetic component, there may be a geographic component, there are obviously dietary differences among the groups, cultural practices, and I think we’re still discovering the factors that lead to higher incidences among populations, and we’re still putting the pieces together.

    Some of this info is old but really classic stuff. This is an older study by Armstrong but it kind of asked the question, “How do people do and which toes do better with ray amputations?” If you have to do a ray amputation, which one is the best one?

    And I think this shows what ray is susceptible to amputation, and it helps paint a picture of -- I’m sorry, of what level, yeah, noticed it. And you can see here, first ray is the most common, and I think in my practice, it’s the one that I tend to see the most.

    If you’re going to do a ray amputation, it’s usually the first ray followed by a fifth ray, and that’s kind of what the data shows here, fifth ray and second ray about 14%. Then you have third ray, fourth ray, and multiple rays are lowest at 6%.

    Multiple rays I’ve only done with extreme infection, still fourth and fifth metatarsals, something like that. It’s not as prevalent. The clear majority of these patients have some other factors such as peripheral arterial disease, about 63%.

    [08:01]

    And a third, about 37% have a previous lower extremity amputation that does not heal and goes on to amputation. And this number becomes repetitive, almost this 30% to 40% number, we’re going to keep saying over and over again. I think that’s the one that’ll stick into your head. It means different things on each slide, but we’ll talk about it some more. We’re going to see it later in the presentation.

    So this -- these next few slides are educational, why people will require amputations. Of course, the classic ulceration infection, neuropathy leading to increased plantar pressure, prolonged activity leading to foot deformity, gangrene. Of course, you might do a ray resection to remove that dead tissue if you have good proximal flow or they’re re-vascularized. A failed toe amputation that maybe the patient walked all over, they have bone exposure, they’ve got a nuanced osteo, or you just need to do a more proximal ray resection to get -- to obtain closure. Trauma, and then we have zebras down here, intolerable pain. There’s always that outlier patient who just has this intolerable pain sometimes, and malignancy also. Those are zebras, but they do play a factor into ray amputations. Excuse me.

    So how do you select what level to amputate? That’s the point of the slide. Pinzer said you want to pick the most distal, functional amputation level with a reasonable potential to support wound healing, a 90% reasonable potential. But how do you get to 90%? What -- you know, how do you look at your patient and say, “Oh, he’s got a 90%, you know, potential to support wound healing”? There are objective ways that you can do this through non-invasive studies, nutritional levels, your pre-albumin, your TcPO2s, so they have, you know, good potential for healing that way.

    [10:01]

    But there’s also surgical ways, meticulous incision planning pre-operatively, make sure you can close it. It’s always better than leaving it open, I think. No pearl-ins, clean out the infection. If you do it for dry gangrene, that’s sometimes better because you can just remove the dead portion and you can close it, versus having to leave it open for a delayed closure.

    So that’s a little bit beyond the scope of this lecture, but one of the questions is always, “Do you have to clear out all of the infection and do a more proximal ray amputation? Or could you do a more distal amputation and close it and let the antibiotics clear out the infection?” I think it’s an art along with the science because nothing you do two times is going to have the same result. You just do what you think is best in the moment.

    So this is the surgical refresher that we’re just going to quickly talk about. You want to do, if you’re doing a central ray dorsal incision over the metatarsal hand -- I’m sorry, the metatarsal shaft, except for the first and fifth, you want to do -- excuse me, if it’s a first -- I tend to do my incision more medial and at the fifth a little lateral so you can obtain good closure. But if you’re central, you want to be dorsal.

    You want to rack it around the digit. Of course, sharply transect the nerves to prevent any stump formation. Ellipse the plantar ulcer if you can. If it’s small enough, you can completely ellipse it. Or if you can’t and it’s large, you just leave what remains for drainage. That works, too.

    Sharply transect any of your tendons. And you want to use power. I know that that can be personal preference, but the research does indicate that power is better, and we’ll talk a little bit about why.

    You want to smooth any bony edges, examine all your tissue planes. Some practitioners can use a non-absorbable suture to re-approximate the metatarsal head capsules to bring the foot -- the metatarsals closer together, narrow it.

    [12:06]

    I tend to do that, I like the way that it looks. I think that the patient sometimes like the -- they can be put off by this, and if you can try to bring the toes together, I think that some patients really like that, if it’s possible.

    You want to irrigate, of course, pulsed lavage. The argument, again, primary versus delayed closure, that is surgeon preference based on infection or what not. And drain if you need to. And I always recommend closure with mattress or simples. I don’t use any type of running. If you need to pop a suture because of swelling, you lose the whole suture line, so. That’s just a small refresher there.

    The question does come up about hypertrophic bone regrowth, and after you do resection and you cut into that medullary bone, and six months later, there’s hypertrophic bone. What -- where does that come from?

    Armstrong did a really great article on this. And what we found was that this hypertrophic bone growth, of course, puts patients at new risk for wounds, new pressure points. And I like this study because there were things that were interesting.

    Heat and cauterization of the sagittal saw or the oscillating saw helps prevent versus just using a hand cutter or a bone cutter. I never tend to put bone wax on a ray resection because it’s form material. And especially if I am concerned about infection, I don’t want to introduce any form material.

    And again, I always use power, but the -- kind of one of the interesting things was regrowth is associated with males, again, manual cutting instruments, so use power if you can, and if you resect distal to the surgical neck. And the important part of this is you don’t really want this regrowth here because you don’t want to have to revise this procedure, if you don’t have to.

    [14:02]

    The next couple slides were the biggest study in Texas, my home state. And it analyzed patients undergoing amputation over a five-year period, looking at different levels, and again, I pulled out the ray data. It just sets the picture of our patient population. Mostly, in this case, they were Hispanic, the usual patient profile, half smoke, a quarter need revascularization, a quarter were dead by the end of the study. So it’s a high risk patient population. And I point this out because that’s the point of the slide. It’s part of the -- who are we doing surgery on? What does this patient like? They’re not always the ideal patient. You’re not always going to get an ideal outcome because of some other factors that go along with this population, so it’s really a one and done procedure.

    This is an interesting slide because it talks about survivability. Who will go on to survivability or who will have more amputation? I kind of broke down the -- this is Umi study and a couple of graphics. It makes it easier. But what they found was one year after having a ray amputation, almost 30% needed another amputation on the same side, on the same -- within one year. At three years, 40%, and at five years, almost half the patients require another procedure on the same foot. And interestingly enough, at five years, almost 30% have to have a procedure on the other foot.

    So, you know, we have to know this, concerning our patients, what’s down the road for them. And we should start to educate the patients. Now that we have all this data, we know, you know, what we’re dealing with. We have to start telling our patients what they’re -- what they are up against. And importantly, I think for me, I’m very interested in caregivers. We have to start telling the caregivers what may be coming down the road.

    [16:02]

    And that is probably more surgery.

    So this is a systematic review of, excuse me, five studies, 435 patients who had first ray amputations. I’m sorry. I got lost here. Mean age was 59, follow up 26 months. Again, 20% had reamputation rates. 37% had to have another digit removed. 20 or sorry, 33% advanced on to transmetatarsal amputation. And almost 30% had to have a below knee amputation.

    And the conclusion here is that one out of every five patients undergoing a partial first ray amputation, they require a more proximal amputation to achieve a durable weight-bearing residual extremity. And I think I’m trying to beat the point home that here is always more than likely going to be another procedure in line for these patients.

    So this is a retrospective review of first ray amputations where they had 60 patients. They followed up just shy of three years. It talks to morbidity and mortality. It doesn’t paint a very good picture because there’s 50% mortality. And I -- this hit home with me because as I was logging for my board certification at the last minute, which I tell my residents never to do, but I was guilty, I work at the VA’s, so when a patient dies and you pull up their chart, it says patient died.

    And as I was logging my resections, every other patient, this patient dies, this patient died, this patient died, and I’ve only been there for a little over three years. So I think I even mentioned to Dr. Frykberg, I said, “Oh my gosh, it’s amazing how many of my patients have died.”

    [18:00]

    And it’s definitely something that you have to understand and I don’t know necessarily that you need to fixate the patient on that, but it’s an interesting statistic, it’s a meaningful statistic. I’ve seen it in practice. Also, 70% will develop a further wound. And that means they have more clinic visits, they need more antibiotics, they need more surgery and they have higher amputation rates.

    So our literature is a mixed bag. We’ve previously said on the last slide that one in five don’t do well. But this one says, the success rate is around 30%. So I know I’m throwing a lot of numbers at you, but it all comes down to actually the patient. It’s hard to say what’s going to happen to Mr. Jones with kidney disease or Mr. Thomas who walks down the hall the minute you do your ray amputation. Nothing is 100% even with the best literature. But these are the numbers and it’s a really good starting point.

    [19:01]

    This is the biomechanics. One of the five Ws that I talked about. What happens to the foot biomechanically? This is what separates us from other surgeons. We know that a first ray will lead to hammer toes above their digits. And the number one complication is transfer lesions. So that’s biomechanics.

    You just have to acknowledge biomechanics in your practice and what your strategy is postoperatively. And more than likely, that’s going to be inserts and shoes. Sometimes additional surgery, but more often than not, it’s just shoes and inserts.

    And this slide talks to distal amputation and the value of it and why it’s important to consider foot salvage versus just cutting a higher level amputation. Overall, there’s a lower mortality rate and a higher rehab potential. And that’s really important. And numbers are really boring, but I’m going to try to explain them to you.

    Over all, there’s a lower mortality rate and a higher rehab potential with ray amputations. A study -- this study was done by Larson, and 70% of people right here, who have a minor amputation, will be able to walk one kilometer at one year.

    [20:09]

    And 19% who have a more proximal amp cannot do that.

    What that really means to me -- I like to reverse the numbers -- 30% will and 80% will not be able to walk. 80% will not be able to walk one kilometer with a higher level amputation. And that’s significant.

    The other significant one is returning home. With a ray resection, 93% of patients will be able to return home, 61% will. If you reverse it, that means that about 40% of people with a higher level amputation will be institutionalized for the rest of their life. And that is significant, especially if that is one of your patients, one of your loved ones.

    Again, 40% will use a prosthetic with a higher level amputation. That means that 60% are in a motorized scooter or wheelchair for the rest of their life. And we all know that when someone goes into a scooter or wheelchair, they never come out, and they decompensate. That leads to more health problems. So I think that these are important numbers to remember. And it’s important, that’s why we promote distal foot procedures and salvage procedures.

    The part and pearl, just really quickly go back again over them. You want to use all the preoperative studies that you can, plan your resection, plan your reconstruction. Preoperative planning is very important. Incision planning, I can’t -- I always tell my residents, incision planning is one of the most important parts of the case, at least to me, because if you can’t close it, it leads to a whole other range of problems.

    You want to try to maintain your metatarsal lengths and the parabola if you can. Sometimes, when you’re doing multiple resections, if they’ve had a prior ray resection, it becomes difficult. If they had a short ray resection, then you have to obviously do a short ray resection.

    [22:03]

    Try to maintain your parabola if you can.

    You want a long plantar flap if you’re creating a stump. Smooth those ends of bounds with a rasp, just, again, to try to prevent that hypertrophic bone regrowth. And insuratic, itself, tissue coverage, you want to prevent those pointing prominences. You want to also, you know, insole shoes.

    And post-operative splinting, it can help prevent contractures if you do get contractures after your surgery.

    And so in conclusion, I guess a lot of factors go into the success of ray amputations. We know the literature, we know -- you know, it hovers around that 30% to 40%. There’s 30% to 40% chance with a -- that you’ll need a first ray resection. There’s -- out of all of them, there’s a 30% to 40% chance that you need a revision.

    So the numbers are important but there’s, you know, four different ways that you can kind of address this issue. Preoperatively, you want to get all of your studies, you want to pick a patient maybe that -- if you can pick the patient and it’s not an emergent or an infectious situation, you want to pick a patient who has got better pre-op values, of course.

    Intra-op, that incision planning I talked about. Use of power, very important. Post-operatively, if they’re compliant, good luck if they’re a VA patient. Of course, you want to identify your risk factors. And then prevention.

    Patient education, I think, is really important. And family education. Promoting those health-seeking behaviors. If they see any wound, come in quickly. Glucose control should get an adjunct procedure, so.

    These are my references. Thank you very much.


    TAPE ENDS [0:23:51]