DIGITAL AMPUTATION PLANNING IN THE DIABETIC PATIENT: The Too Few Toes Principle

The US spends one in fi ve health care dollars on the care of diabetic patients, with the total cost of diagnosed diabetes estimated at over $245 billion in 2012 (1). For the diabetic patient with at least one form of foot disease, (defi ned as the presence of neuropathy, peripheral arterial disease, foot deformity, active infection, ulceration or gangrene in at least one lower extremity) the odds of inpatient mortality and length of hospital stay are respectively 31% and 101% greater when compared to similar patients without any foot disease (2). Likewise, the correlation between diabetes related foot ulcers and a progressive decline in patient quality of life is already well described in the literature (3-7). In 2008 alone, surgeons performed 67,000 foot amputations in patients with diabetes within the US, many of which were attempts at limb salvage. Diabetic foot amputations often require revisional procedures and are associated with increased morbidity, costs to the patient and healthcare system, and serial loss of function. Although much has been written about hallux and partial forefoot amputations, little attention is directed towards preoperative planning of digital amputations in the diabetic patient. While a global mindset of limb salvage and gratuitous tissue loss prevention may be ideal, there may be circumstances in which saving residual toes may greatly increase the patient’s risk for ulceration and additional surgery. Therefore, due diligence on behalf of the surgeon in the initial selection of amputation level may greatly benefi t the patient’s postoperative function and long-term outcomes. In this article, the authors suggest an algorithm for preoperative digital amputation selection, which we have found to best optimize post-amputation ambulation and reduce high reulceration risk scenarios in the diabetic patient requiring digital amputation.