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

In reply: We appreciate the opportunity to reply to two letters submitted in response to our article.1

Both letters agree that our perspective piece was mainly based on evidence about the outcomes for people with transmetatarsal amputation, noting that most people undergo amputation of the toe(s) or toes and metatarsals. As highlighted in our supporting work,2 there are comparatively few investigations focusing on outcomes for people with digital, ray, tarsometatarsal and transtarsal amputation. Despite this, we stand by our interpretation that the rates of complications and reamputation seem very similar across levels of partial foot amputation.1,2 To illustrate, a study that stratified large numbers of people by level of partial foot amputation found that the rates of ipsilateral reamputation were not statistically different in groups with either toe, ray or mid-foot (ie, transmetatarsal, Lisfranc and Chopart) amputation.3 Given these data, we argue that our synthesis of published outcomes on the rates of reamputation and other complications for people with different levels of partial foot amputation was reasonable. Our article should not be considered a comparison between the outcomes of transmetatarsal and transtibial amputation.

We do not believe that current data show that toe amputations are becoming more common in Australia. The age-standardised incidence of toe amputation remained stable between 2000 and 2010, while the incidence of partial foot amputation at the toe and metatarsal level and transmetatarsal level increased.4

We are not advocating that more transtibial amputations should be considered to minimise the risk of complications and further amputations. Rather, clinicians should consider the emerging evidence when communicating the perceived benefits to patients; particularly given that this evidence challenges long-held beliefs.2

We are grateful for the opportunity to promote discussion and highlight awareness of the need for further research into outcomes for people facing difficult decisions about limb loss.