TAPE STARTS â [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 canât 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 sheâs been a welcomed blessing to our unit and our programs. So, letâs welcome Dr. Jacqueline Marino.
You should have sat in the front.
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Okay. There you go.
Jacqueline Marino: Okay, thank you. Good morning. I just want to say that itâs an honor to talk to you all.
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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 Iâm also an Attending Surgical Podiatrist there. And Iâm speaking today about ray amputations with -- which is something that we do often. And if you were at the VA, Iâm sure you do it often, too.
My talk today is going to serve as just a refresher. Itâs 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 donât have any relevant disclosures for this. So thatâs pretty simple.
What are our objectives today? Itâs 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. Itâs -- thereâs evidence-based medicine to support that you want to do a more distal procedure versus the proximal amputation and weâll kind of get into that and why thatâs 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. Iâm 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, theyâre 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 weâre 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 yearâs worth of Medicare data. Itâs an older study but itâs 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, Iâm sure there are better numbers on this, but itâs just to set the stage of what weâre dealing with in the cost realm. But mainly who do ray amputations affect? And theyâre 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 thatâs pretty significant. Weâre going to start to see numbers, a lot of numbers, but Iâm 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 thatâs the take home here, and I like the last bullet which is the same thing, like I donât know if itâs 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 thatâs 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 weâre still discovering the factors that lead to higher incidences among populations, and weâre 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, âHow do people do and which toes do better with ray amputations?â 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 -- Iâm sorry, of what level, yeah, noticed it. And you can see here, first ray is the most common, and I think in my practice, itâs the one that I tend to see the most.
If youâre going to do a ray amputation, itâs usually the first ray followed by a fifth ray, and thatâs 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 Iâve only done with extreme infection, still fourth and fifth metatarsals, something like that. Itâs 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, weâre going to keep saying over and over again. I think thatâs the one thatâll stick into your head. It means different things on each slide, but weâll talk about it some more. Weâre 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 theyâre re-vascularized. A failed toe amputation that maybe the patient walked all over, they have bone exposure, theyâve 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. Thereâs 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? Thatâs 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, âOh, heâs got a 90%, you know, potential to support wound healingâ? 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 thereâs also surgical ways, meticulous incision planning pre-operatively, make sure you can close it. Itâs always better than leaving it open, I think. No pearl-ins, clean out the infection. If you do it for dry gangrene, thatâs 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 thatâs a little bit beyond the scope of this lecture, but one of the questions is always, âDo 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?â I think itâs 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 weâre just going to quickly talk about. You want to do, if youâre doing a central ray dorsal incision over the metatarsal hand -- Iâm sorry, the metatarsal shaft, except for the first and fifth, you want to do -- excuse me, if itâs 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 youâre 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 itâs small enough, you can completely ellipse it. Or if you canât and itâs 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 weâll 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 itâs 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 donât use any type of running. If you need to pop a suture because of swelling, you lose the whole suture line, so. Thatâs 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, thereâs 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 itâs form material. And especially if I am concerned about infection, I donât 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 donât really want this regrowth here because you donât want to have to revise this procedure, if you donât 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 itâs a high risk patient population. And I point this out because thatâs the point of the slide. Itâs part of the -- who are we doing surgery on? What does this patient like? Theyâre not always the ideal patient. Youâre not always going to get an ideal outcome because of some other factors that go along with this population, so itâs 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, whatâs 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 weâre dealing with. We have to start telling our patients what theyâre -- what they are up against. And importantly, I think for me, Iâm 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. Iâm 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 Iâm 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 doesnât paint a very good picture because thereâs 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 VAâs, 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 Iâve only been there for a little over three years. So I think I even mentioned to Dr. Frykberg, I said, âOh my gosh, itâs amazing how many of my patients have died.â
[18:00]
And itâs definitely something that you have to understand and I donât know necessarily that you need to fixate the patient on that, but itâs an interesting statistic, itâs a meaningful statistic. Iâve 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. Weâve previously said on the last slide that one in five donât do well. But this one says, the success rate is around 30%. So I know Iâm throwing a lot of numbers at you, but it all comes down to actually the patient. Itâs hard to say whatâs 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 itâs 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 thatâs biomechanics.
You just have to acknowledge biomechanics in your practice and what your strategy is postoperatively. And more than likely, thatâs going to be inserts and shoes. Sometimes additional surgery, but more often than not, itâs just shoes and inserts.
And this slide talks to distal amputation and the value of it and why itâs important to consider foot salvage versus just cutting a higher level amputation. Overall, thereâs a lower mortality rate and a higher rehab potential. And thatâs really important. And numbers are really boring, but Iâm going to try to explain them to you.
Over all, thereâs 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 thatâs 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 itâs important, thatâs 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 canât -- I always tell my residents, incision planning is one of the most important parts of the case, at least to me, because if you canât 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 youâre doing multiple resections, if theyâve 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 youâre 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%. Thereâs 30% to 40% chance with a -- that youâll need a first ray resection. Thereâs -- out of all of them, thereâs a 30% to 40% chance that you need a revision.
So the numbers are important but thereâs, 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 itâs 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 theyâre compliant, good luck if theyâre 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.
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