Does reconstruction preserving the first or first two rays benefit over full transmetatarsal amputation in diabetic foot?

Background: The benefits of total transmetatarsal amputation (TMA) over higher level amputation are well known. However, there are no studies evaluating the effects of first or the first two ray sparing transmetatarsal amputation with flap coverage. We evaluated this approach in regards to functional outcome and to identify long-term complications. Material and Method: Retrospective data of 59 patients were evaluated according to their surgical method. Complete TMA with free flap reconstruction was designated as group TMA with 27 patients and first or first two rays preserving TMA with free flap reconstruction was designated as group Ray with 32 patients. Demographics, flap outcomes, additional procedures after initial healing and functional outcomes were measured and evaluated. Results: There was no statistical significant difference in demographic distribution and flap outcomes in either group except poor blood sugar control in group Ray. Additional procedures after initial healing showed no statistical difference but the tendency of minor procedures was higher in group Ray. The maximum achieved ambulatory function was significantly better in group Ray with an ambulatory function score of 4.4 over 3.7 in group TMA (p= 0.012). Conclusion: The preservation of the first or first two rays with free flap reconstruction may functionally benefit the patients despite the higher tendency of 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. Conflict of interest: The authors have no conflict of interest of any kind regarding this article. Address correspondence to: Joon Pio Hong, M.D., Ph.D., M.M.M., Professor, Department of Plastic and Reconstructive Surgery, University of Ulsan, College of Medicine, Asan Medical Center, 88 Olympic-ro 43 gil, SongPa-Gu, Seoul 05505, Korea. ©2018American Society of Plastic Surgeons