Volume 200 - Issue 11
Partial foot amputations may not always be worth the risk of complications
Authors: Peter A Lazzarini, Matthew Malone and Paul R Wraight
Med J Aust 2014; 200 (11): 636. || doi: 10.5694/mja14.00476
Published online: 16 June 2014
Published online: 16 June 2014
Dillon et al should be read as comparing transmetatarsal amputation and below-knee amputation outcomes
To the Editor: Dillon and colleagues present a challenging perspective on the evidence comparing partial foot amputation (PFA) and below-knee amputation (BKA) outcomes.1,2 Australia's diabetes-related major amputation rates have only recently reduced to international levels3 and we fear that any oversimplistic perspectives may be detrimental to these improved rates and, importantly, to our patients. Thus, we believe these articles1,2 should be read cognisant of some important points.
First, the authors correctly identify that 75% of Australia's amputations are PFAs (toe, ray or transmetatarsal amputations [TMAs]),4 yet base their PFA arguments nearly entirely on TMA literature.1,2 TMAs are complex procedures and make up just 5%–10% of PFAs.4 Thus, we believe the article should be primarily read as a comparison between TMA and BKA outcomes.
Second, the authors correctly report higher ipsilateral reamputation risks for TMAs compared with BKAs;1,2 however, they omit lower contralateral amputation risks5 and somewhat dismiss well reported lower mortality risks.1,2,5
Last, the authors conclude “very similar functional outcomes” from data comparing methodologically different TMA studies with BKA studies or data within heterogeneous and underpowered studies.1,2 These definitive interpretations may be misleading, especially given the statistically significant functional benefits of TMAs compared with BKAs, as reported in the higher impact studies the authors cite.2,6
We thank Dillon et al for highlighting such a large, yet silent, burden of disease and hope this letter will provide more balance to this crucial life-changing decision facing 8000 Australians and their clinicians this year.4
Competing interests
No relevant disclosures.
References
- Dillon MP, Fatone S, Morris ME. Partial foot amputation may not always be worth the risk of complications. Med J Aust 2014; 200: 252-253. 1
- Dillon MP, Fatone S. Deliberations about the functional benefits and complications of partial foot amputation: do we pay heed to the purported benefits at the expense of minimizing complications? Arch Phys Med Rehabil 2013; 94: 1429-1435. 2
- Organisation for Economic Co-operation and Development (OECD). Health Care Quality Indicators: Primary Care: Diabetes lower extremity amputation. France, OECD 2013. http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT (accessed Mar 2014).
- Dillon MP, Kohler F, Peeva V. Incidence of lower limb amputation in Australian hospitals from 2000 to 2010. Prosthet Orthot Int 2014; 38: 122-132. 4
- Izumi Y, Satterfield K, Lee S, Harkless LB. Risk of reamputation in diabetic patients stratified by limb and level of amputation: a 10-year observation. Diabetes Care 2006; 29: 566-570. lefthere
- Kanade RV, van Deursen RW, Harding K, Price P. Walking performance in people with diabetic neuropathy: benefits and threats. Diabetologia 2006, 49: 1747-1754. 6