Partial foot amputations may not always be worth the risk of complications

To the Editor: In their recent article, Dillon and colleagues cite reports that the incidence of partial foot amputations is rising and that the functional outcome of these amputations is poor.1 They express difficulty in understanding “why the high risk of complications and secondary amputations associated with partial foot amputation do not weigh more heavily in decisions about amputation surgery”. Finally, they propose that more transtibial than partial foot amputations should be considered to minimise the risk of complications and further amputation.

The authors' argument is misleading as they combine two very different entities, toe amputation and major forefoot amputation, as the single entity of “partial foot amputation”. As their own work has shown,2 toe amputations make up 90% of all “partial foot amputations” and it is mainly toe amputations that are becoming more common. The evidence they cite about complications and poor outcomes in “partial foot amputations” is based exclusively on (less commonly performed) transmetatarsal and midfoot amputations, and not on toe amputations. While the early morbidity of toe (±metatarsal head) amputation is not insignificant, the late functional outcomes are likely to be more favourable than transmetatarsal or midtarsal amputation.

Our interpretation of the available evidence is that the rising incidence of “partial foot amputations” is driven by more toe amputations in the increasing number of people with type 2 diabetes. This preserves acceptable function and may be contributing to the decline in major amputations. We acknowledge that further research is needed to clarify the relationship between these diverging trends.